A Randomized Controlled Trial of a Trauma-Informed Support, Skills, and Psychoeducation Intervention for Survivors of Torture and Related Trauma in Kurdistan, Northern Iraq

Judith Bass; Sarah McIvor Murray; Thikra Ahmed Mohammed; Mary Bunn; William Gorman; Ahmed Mohammed Amin Ahmed; Laura Murray; Paul Bolton

doi:10.9745/GHSP-D-16-00017

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FIGURE
Flow Chart of Study Participants
^a295 individuals were screened at baseline and 209 randomized. However, data at baseline were missing for 2 individuals randomized to the intervention and followed‐up; thus, we had data for only 293 people screened and 207 randomized.
^b Of the 5 people allocated to the study intervention who did not receive it, 3 opted for financial support, 1 was assigned to a counselor who quit, and the last person’s reasons were unknown.

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TABLE 1 HAI Refresher Training Techniques and Activities for CMHWs

Techniques	Activities
Psychoeducation	Give clients, families, or communities information on psychological problems.
	Reduce stigma about problems and treatment.
	Teach how thoughts, behaviors, and feelings can influence each other positively.
	Explain how talk therapy can help.
Treatment planning	Make arrangements with the client to begin treatment (e.g., confidentiality).
	Agree on how to continue treatment (e.g., weekly sessions, involving family if needed).
	Explain the way treatment will end.
	Describe follow-up assistance if needed after sessions end.
Empowerment	Help clients develop skills and use positive actions and attitudes.
	Start with small changes and help them focus on better parts of life, not only problems.
	Grow from a view of themselves as dependent to better able to care for themselves.
	Reduce feelings of helplessness by being more active and involved with family and community.
Motivation	Encourage clients to come to treatment regularly and make recommended changes in their behavior and thinking.
	Normalize their problems.
	Emphasize the progress they are making.
	Use the treatment relationship for emotional support with empathic listening and reflective techniques.
Crisis management	Assess for suicide or self-injury.
	Use safety plan if needed.
	Be more directive if needed.
	Involve family or other resources if needed.
	Get more consultation and supervision if needed.
	Change the balance between strengths and supports vs. stresses to manage the crisis.
Medication management	Explain how drug therapy can combine with talk therapy to help reduce negative feelings and improve sleep and other problems.
	Advise against the use of alcohol or illegal drugs, which can worsen problems.
	Consult with the physician about a combined therapy plan.
	Monitor for side effects and encourage daily use for later improvement.
Strength building	Identify the skills clients already have.
	Remind them how they have solved problems before.
	Find new ways to feel better, like talking about what is inside.
	Express concern for the negative parts of the client’s life but focus more on the positive (e.g., love of God or their children).
	Emphasize client’s ways of taking care of themselves (e.g., time with friends).
Stress reduction	Assess and encourage client’s interests in positive activities (e.g., praying, exercising).
	Teach relaxation techniques like deep breathing and focusing inside.
	Practice relaxation regularly in counseling and have clients use it at home daily.
	Help clients use relaxation techniques any time they are upset, worried, or cannot sleep.
Advocacy	Identify resources in the family or community that can be used for additional client support.
	Help the client get additional needed services (e.g., medical or legal assistance).
	Promote human rights with equal protection, respect, and benefits for everyone.
	Try to end domestic abuse or child abuse and gender-based violence.
	Connect with other government offices, community programs, and NGOs to increase public awareness about mental health problems and find solutions.

Abbreviations: CMHW, community mental health worker; HAI, Heartland Alliance International.

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TABLE 2 Baseline Characteristics of Intent-to-Treat Sample, Dohuk Governorate, Kurdistan, June 2009–June 2010 (N = 207)

	Counseling Intervention (n = 157)^a	Waitlist Control (n = 50)
Age, years, mean (SD)	40.30 (15.3)	40.76 (12.82)
Female, No. (%)	54 (34%)	15 (30%)
No. of children, mean (SD)	4.80 (4.09)	4.86 (3.91)
Disabled, No. (%)	32 (20%)	9 (18%)
Marital status
Married, No. (%)	116 (74%)	43 (86%)
Single/divorced/widowed, No. (%)	41 (26%)	7 (14%)
Employment
Not working, No. (%)	87 (55%)	26 (52%)
Regular work, No. (%)	27 (17%)	11 (22%)
Self-employed, No. (%)	23 (15%)	8 (16%)
Irregular work, No. (%)	20 (13%)	5 (10%)
Education
None, No. (%)	68 (43%)	24 (48%)
Primary, No. (%)	53 (34%)	14 (28%)
Secondary, No. (%)	29 (18%)	11 (22%)
Bachelors/institutional degree or certificate, No. (%)	7 (4%)	1 (2%)

Abbreviation: SD, standard deviation.
↵a 159 were allocated to the counseling intervention, but 2 participants’ paperwork at baseline was lost.

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TABLE 3 Adjusted Treatment Effects on Primary and Secondary Study Outcomes,^a Dohuk Governorate, Kurdistan, June 2009–June 2010 (N = 209)

	Counseling Intervention (n = 159) Score (95% CI)	Waitlist Control (n = 50) Score (95% CI)	Adjusted Net Effect Score (95% CI)	Effect Size Estimate^b	P Value
Primary Outcomes
Depression
Baseline	1.61 (1.51, 1.71)	1.59 (1.44, 1.74)
Follow-up	0.78 (0.67, 0.89)	0.97 (0.75, 1.20)
Pre-post change	-0.83 (-0.98, -0.69)	-0.62 (-0.86, -0.37)	-0.22 (-0.39, -0.04)	0.57	.02
Functional impairment
Baseline	1.92 (1.69, 2.15)	1.86 (1.56, 2.16)
Follow-up	1.16 (0.95, 1.38)	1.49 (1.15, 1.83)
Pre-post change	-0.76 (-1.06, -0.45)	-0.37 (-0.83, 0.09)	-0.39 (-0.74, -0.03)	0.53	.03
Secondary Outcomes
Post-traumatic stress
Baseline	1.34 (1.22, 1.46)	1.35 (1.17, 1.52)
Follow-up	0.73 (0.64, 0.83)	0.86 (0.69, 1.04)
Pre-post change	-0.61 (-0.74, -0.48)	-0.48 (-0.68, -0.29)	-0.13 (-0.27, 0.01)	0.35	.07
Anxiety
Baseline	1.30 (1.17, 1.43)	1.25 (1.08, 1.41)
Follow-up	0.66 (0.53, 0.80)	0.81 (0.59, 1.03)
Pre-post change	-0.64 (-0.83, -0.44)	-0.44 (-0.67, -0.21)	-0.19 (-0.35, -0.04)	0.41	.01
Traumatic grief
Baseline	0.87 (0.74, 1.01)	0.86 (0.68, 1.03)
Follow-up	0.38 (0.31, 0.44)	0.47 (0.32, 0.62)
Pre-post change	-0.50 (-0.59, -0.40)	-0.38 (-0.50, -0.27)	-0.11 (-0.24, 0.02)	0.26	.08

Abbreviation: CI, confidence interval.
↵a Model-estimated differences after adjusting for age, sex, employment status, time between assessments, number of children, and marital status in all models. All models include multiple imputation by chained equations for missing data and for missing outcomes due to loss to follow-up. Robust standard error estimators are used to account for clustering by counselor.
↵b Measured using Cohen’s d statistic and pooled baseline variances.