The impact of Cognitive Processing Therapy on stigma among survivors of sexual violence in eastern Democratic Republic of Congo: results from a cluster randomized controlled trial

S M Murray, J Augustinavicius, D Kaysen, D Rao, L K Murray, K Wachter, J Annan, K Falb, P Bolton, J K Bass, S M Murray, J Augustinavicius, D Kaysen, D Rao, L K Murray, K Wachter, J Annan, K Falb, P Bolton, J K Bass

Abstract

Background: Sexual violence is associated with a multitude of poor physical, emotional, and social outcomes. Despite reports of stigma by sexual violence survivors, limited evidence exists on effective strategies to reduce stigma, particularly in conflict-affected settings. We sought to assess the effect of group Cognitive Processing Therapy (CPT) on stigma and the extent to which stigma might moderate the effectiveness of CPT in treating mental health problems among survivors of sexual violence in the Democratic Republic of Congo.

Methods: Data were drawn from 405 adult female survivors of sexual violence reporting mental distress and poor functioning in North and South Kivu. Women were recruited through organizations providing psychosocial support and then cluster randomized to group CPT or individual support. Women were assessed at baseline, the end of treatment, and again six months later. Assessors were masked to women's treatment assignment. Linear mixed-effect regression models were used to estimate (1) the effect of CPT on feelings of perceived and internalized (felt) stigma, and (2) whether felt stigma and discrimination (enacted stigma) moderated the effects of CPT on combined depression and anxiety symptoms, posttraumatic stress, and functional impairment.

Results: Participants receiving CPT experienced moderate reductions in felt stigma relative to those in individual support (Cohen's D = 0.44, p = value = 0.02) following the end of treatment, though this difference was no longer significant six-months later (Cohen's D = 0.45, p = value = 0.12). Neither felt nor enacted stigma significantly moderated the effect of CPT on mental health symptoms or functional impairment.

Conclusions: Group cognitive-behavioral based therapies may be an effective stigma reduction tool for survivors of sexual violence. Experiences and perceptions of stigma did not hinder therapeutic effects of group psychotherapy on survivors' mental health.

Trial registration: ClinicalTrials.gov NCT01385163.

Keywords: Cognitive therapy; Psychotherapy; Rape; Sexual violence; Social stigma; Sub-Saharan Africa.

Conflict of interest statement

Oral informed consent was obtained from all individual participants included in the study. The Johns Hopkins Bloomberg School of Public Health and the Kinshasa School of Public Health Institutional Review Boards provided ethical approval for the trial.Not applicableThe authors declare that they have no competing interests.Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

References

    1. Johnson K, Scott J, Rughita B, Kisielewski M, Asher J, Ong R, et al. Association of sexual violence and human rights violations with physical and mental health in territories of the eastern Democratic Republic of the Congo. JAMA. J Am Med Assoc. 2010;304:553–562. doi: 10.1001/jama.2010.1086.
    1. Abrahams N, Devries K, Watts C, Pallitto C, Petzold M, Shamu S, et al. Worldwide prevalence of non-partner sexual violence: a systematic review. Lancet. 2014;383:1648–1654. doi: 10.1016/S0140-6736(13)62243-6.
    1. Dossa NI, Zunzunegui MV, Hatem M, Fraser W. Fistula and other adverse reproductive health outcomes among women victims of conflict-related sexual violence: a population-based cross-sectional study. Birth. 2014;41:5–13. doi: 10.1111/birt.12085.
    1. Verelst A, De Schryver M, Broekaert E, Derluyn I. Mental health of victims of sexual violence in eastern Congo: associations with daily stressors, stigma, and labeling. BMC Womens Health. 2014;14(106)
    1. Kohli A, Tosha M, Ramazani P, Safari O, Bachunguye R, Zahiga I, et al. Family and community rejection and a Congolese led mediation intervention to reintegrate rejected survivors of sexual violence in eastern Democratic Republic of Congo. Health Care Women Int. 2013;34:736–756. doi: 10.1080/07399332.2012.721418.
    1. Kelly J, Kabanga J, Cragin W, Alcayna-Stevens L, Haider S, Vanrooyen MJ. If your husband doesn't humiliate you, other people won’t’: gendered attitudes towards sexual violence in eastern Democratic Republic of Congo. Glob Public Health. 2012;7:285–298. doi: 10.1080/17441692.2011.585344.
    1. Link BG, Phelan JC. Stigma And its public health implications. Lancet. 2006;367:528–529. doi: 10.1016/S0140-6736(06)68184-1.
    1. Kohli A, Perrin NA, Mpanano RM, Mullany LC, Murhula CM, Binkurhorhwa AK, et al. Risk for family rejection and associated mental health outcomes among conflict-affected adult women living in rural eastern Democratic Republic of the Congo. Health Care Women Int. 2014;35:789–807. doi: 10.1080/07399332.2014.903953.
    1. Kelly JT, Betancourt TS, Mukwege D, Lipton RI, Vanrooyen MJ. Experiences of female survivors of sexual violence in eastern Democratic Republic of the Congo: a mixed-methods study. Confl Health. 2011;5:25. doi: 10.1186/1752-1505-5-25.
    1. Verelst A, De Schryver M, De Haene L, Broekaert E, Derluyn I. The mediating role of stigmatization in the mental health of adolescent victims of sexual violence in eastern Congo. Child Abuse Negl. 2014;38:1139–1146. doi: 10.1016/j.chiabu.2014.04.003.
    1. Mathias K, Kermode M, Sebastian MS, Koschorke M, Goicolea I. Under the banyan tree - exclusion and inclusion of people with mental disorders in rural North India. BMC Public Health. 2015;15:446. doi: 10.1186/s12889-015-1778-2.
    1. Kohli A, Perrin N, Mpanano RM, Case J, Murhula CM, Binkurhorhwa AK, et al. Social interaction in the aftermath of conflict-related trauma experiences among women in Walungu territory, Democratic Republic of Congo. Glob. Public Health. 2015;10:55–70. doi: 10.1080/17441692.2014.972426.
    1. Weiss MG, Ramakrishna J. Stigma interventions and research for international health. Lancet. 2006;367:536–538. doi: 10.1016/S0140-6736(06)68189-0.
    1. Rao D, Desmond M, Andrasik M, Rasberry T, Lambert N, Cohn SE, et al. Feasibility, acceptability, and preliminary efficacy of the unity workshop: an internalized stigma reduction intervention for African American women living with HIV. AIDS Patient Care STDs. 2012;26:614–620. doi: 10.1089/apc.2012.0106.
    1. Stangl AL, Lloyd JK, Brady LM, Holland CE, Baral S. A systematic review of interventions to reduce HIV-related stigma and discrimination from 2002 to 2013: how far have we come? J Int AIDS Soc. 2013;16:18734. doi: 10.7448/IAS.16.3.18734.
    1. Resick PA, Schnicke MK. Cognitive processing therapy for sexual assault victims. J Consult Clin Psychol. 1992;60:748–756. doi: 10.1037/0022-006X.60.5.748.
    1. Bass JK, Annan J, McIvor Murray S, Kaysen D, Griffiths S, Cetinoglu T, et al. Controlled trial of psychotherapy for Congolese survivors of sexual violence. N Engl J Med. 2013;368:2182–2191. doi: 10.1056/NEJMoa1211853.
    1. Hall BJ, Bolton PA, Annan J, Kaysen D, Robinette K, Cetinoglu T, et al. The effect of cognitive therapy on structural social capital: results from a randomized controlled trial among sexual violence survivors in the Democratic Republic of the Congo. Am J Public Health. 2014;104:1680–1686. doi: 10.2105/AJPH.2014.301981.
    1. Iverson KM, King MW, Cunningham KC, Resick PA. Rape survivors’ trauma-related beliefs before and after cognitive processing therapy: associations with PTSD and depression symptoms. Behav Res Ther. 2015;66:49–55. doi: 10.1016/j.brat.2015.01.002.
    1. Shuman SJ, Falb KL, Cardoso LF, Cole H, Kpebo D, Gupta J. Perceptions and experiences of intimate partner violence in Abidjan, Côte d’Ivoire. PLoS One. 2016;11:e0157348. doi: 10.1371/journal.pone.0157348.
    1. Bartels SA, Scott JA, Leaning J, Kelly JT, Joyce NR, Mukwege D, et al. Demographics and care-seeking behaviors of sexual violence survivors in south Kivu Province, Democratic Republic of Congo. Disaster Med Public Health Prep. 2012;6:393–401. doi: 10.1001/dmp.2012.66.
    1. Sirey JA, Bruce ML, Alexopoulos GS, Perlick DA, Friedman SJ, Meyers BS. Stigma as a barrier to recovery: perceived stigma and patient-rated severity of illness as predictors of antidepressant drug adherence. Psychiatr Serv. 2001;52:1615–1620. doi: 10.1176/appi.ps.52.12.1615.
    1. Tadesse S. Stigma against tuberculosis patients in Addis Ababa, Ethiopia. PLoS One. 2016;11:e0152900. doi: 10.1371/journal.pone.0152900.
    1. McMahon SA, Kennedy CE, Winch PJ, Kombe M, Killewo J, Kilewo C. Stigma, Facility constraints, and personal disbelief: why women disengage from HIV care during and after pregnancy in Morogoro region, Tanzania. AIDS Behav. 2017;21:317–329. doi: 10.1007/s10461-016-1505-8.
    1. Resick PA, Nishith P, Weaver TL, Astin MC, Feuer CA. A comparison of cognitive-processing therapy with prolonged exposure and a waiting condition for the treatment of chronic posttraumatic stress disorder in female rape victims. J Consult Clin Psychol. 2002;70:867–879. doi: 10.1037/0022-006X.70.4.867.
    1. Murray LK, Dorsey S, Bolton P, Jordans MJ, Rahman A, Bass J, et al. Building capacity in mental health interventions in low resource countries: an apprenticeship model for training local providers. Int J Ment Health Syst. 2011;5:30. doi: 10.1186/1752-4458-5-30.
    1. Bolton P, Tang AM. An alternative approach to cross-cultural function assessment. Soc Psychiatry Psychiatr Epidemiol. 2002;37:537–543. doi: 10.1007/s00127-002-0580-5.
    1. Murray SM, Robinette KL, Bolton P, Cetinoglu T, Murray LK, Annan J, et al. Stigma among survivors of sexual violence in Congo: scale development and psychometrics. J Interpers Violence. 2015;
    1. Azur MJ, Stuart EA, Frangakis C, Leaf PJ. Multiple imputation by chained equations: what is it and how does it work? Int J Methods Psychiatr Res. 2011;20:40–49. doi: 10.1002/mpr.329.
    1. Cohen J. Statistical power analysis for the behavioral sciences. Hillsdale, New Jersey: Lawrence Erlbaum Associates; 1988.
    1. StataCorp. Stata statistical software: Release 13. College Station, TX: StataCorp LP; 2013.
    1. Livingston JD, Milne T, Fang ML, Amari E. The effectiveness of interventions for reducing stigma related to substance use disorders: a systematic review. Addict Abingdon Engl. 2012;107:39–50. doi: 10.1111/j.1360-0443.2011.03601.x.
    1. Knight MTD, Wykes T, Hayward P. Group treatment of perceived stigma and self-esteem in schizophrenia: a waiting list trial of efficacy. Behav Cogn Psychother. 2006;34:305–318. doi: 10.1017/S1352465805002705.
    1. Ertl V, Pfeiffer A, Schauer E, Elbert T, Neuner F. Community-implemented trauma therapy for former child soldiers in northern Uganda: a randomized controlled trial. JAMA. 2011;306:503–512. doi: 10.1001/jama.2011.1060.
    1. Bass J, Murray S, Cole G, Bolton P, Poulton C, Robinette K, et al. Economic, social and mental health impacts of an economic intervention for female sexual violence survivors in Eastern Democratic Republic of Congo. Glob. Ment. Health. 2016;e19.

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