by Amy Myers –
The New England Journal of Medicine recently published a report on the use of psychotherapy in treating the after-effects of sexual violence in the Democratic Republic of Congo (DRC). War and violence in the DRC have claimed more than 5.4 million lives since 1998 and earned it the distinction of rape capital of the world. Even after “peace” was declared in 2002, violence continues with sexual violence occurring everywhere – even in the refugee camps. Survivors of sexual violence often suffer from mental health issues including Post Traumatic Stress Disorder (PTSD). A research team from Johns Hopkins, the University of Washington, and the International Rescue Committee identified that treatment for these symptoms has been proven effective in high-income countries, however very little evidence exists for the use of these treatments in low-income, conflict-ridden nations.
The study details the introduction of group psychotherapy into 16 villages in the DRC. 405 women completed multiple assessments throughout the research period. Some villages were provided group therapy administered by psychosocial assistants trained by the research team. The control villages provided only individual support to survivors.
The results (see table below) at the end of treatment and six months following show a substantial decrease in both the scores for Depression and Anxiety and PTSD. The findings show that the risk of meeting criteria for post-violence mental health issues is much higher when survivors are only offered individual support than when they are offered group psychotherapy.
While this study supports the effectiveness of group therapy in low-income countries, there are some important differences that occurred to me while reading this report. In the U.S., while mental health care continues to carry a stigma and is challenged by insurance parity, it is much more widely accepted than in low-income countries. Especially group therapy – in many ways it’s been ingrained in our pop culture, from television characters like Frasier Crane to celebrity rehab to radio call-in shows where you can share your innermost thoughts with millions.
So how is it that the same practice could be applied in a low-income, conflict-torn country and have the same impact? The study along with an accompanying editorial briefly discusses the impact that social norms and culture can have on the acceptance of group therapy as a treatment option:
“Even as we pursue this necessary search for effective, scalable methods of providing psychological support…, we should exercise caution in rolling out various techniques. Mental health has local, social, and cultural aspects that influence the acceptability and effectiveness of psychological support in different groups. Although treating psychiatric disorders is essential, service providers adopting various promising techniques for addressing post-trauma reactions must be careful not to allow interventions to pathologize, distress, or inadvertently stigmatize people who may already feel (and be) marginalized.” (Watts, et al)
Furthermore, what impact does on-going violence in the DRC have on the efficacy of treatment? Are the survivors able to move past this incidence of violence without living in fear of it happening again? In the process of writing this post I was able to work with Sandeep Prasanna, a law student at UCLA who traveled to the DRC as part of an anthropological research project that was presented to the International Criminal Court earlier this spring. (You can read more about that project here). I asked Sandeep about the ongoing violence in the DRC and the environment for healing that it creates in this country. Here is his response:
Our time in the DRC was emotionally challenging. The Congolese people we spoke with had been subjected to violence that none of us could ever fathom. Speaking with survivors and other Congolese people allowed us to begin to understand the social and psychological repercussions of the conflict in the Kivus [provinces]. Our time there was intense but relatively short, so in the end we were exposed to one small piece of a very complex puzzle. My team was based in South Kivu, where we were looking at the village-level effects of atrocities like mass rape.
In many villages in South Kivu, the atmosphere is deeply tense. It seemed like the constant violence had permeated the social fabric of the villages we went to. It’s hard to imagine what that sort of experience does to an individual’s psyche– but certainly, a few months or even a few years break from violence doesn’t seem like it would be enough to undo the damage done to villages in South Kivu. The effects aren’t just temporary: along with long-lasting individual psychological trauma, there seem to be higher rates of spousal separation; higher rates of PTSD and depression; newborn children with “negative” names alluding to the circumstances of their birth; and seriously diminished economic activity. These effects don’t just go away quickly – they persist for years and serve as explicit and implicit reminders of the violence. In the DRC’s case, since the violence hasn’t yet subsided, it seems like it will take many, many years for the repercussions of the violence to go away.
Sandeep attests, from firsthand experience, to how badly the region was affected. It’s hard to imagine any type of psychotherapy could be effective amidst such violence, but yet the study shows a reduction in the occurrence of post-violence mental health issues through the use of group therapy.
The research team from Johns Hopkins and the University of Washington has provided a desperately needed treatment method in the DRC. But, much like the situation in Nairobi that Mike described, it touches the symptoms, the results, not the root cause. There is still plenty to be done in the DRC to keep women from having to experience the terror and shame of sexual violence. Nearly 40% of women have experienced sexual violence in the DRC where political and economic instability are an everyday reality. Research like this study and the one in Nairobi are just the first steps in stopping this global tragedy.
Amy earned her MHA from the University of Missouri and works in healthcare market analysis and strategic planning.
Follow her on Twitter @amyloumyers or subscribe to the blog.