Evaluation of the efficacy of a South African psychosocial framework for the rehabilitation of torture survivors
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34
SCIENTIFIC ARTICLE
Evaluation of the efficacy of a South
African psychosocial framework for
the rehabilitation of torture
survivors
Dominique Dix-Peek*, Merle Werbeloff**
Abstract
Key issues box: Introduction: To address the consequences
• When treating torture survivors of past torture experiences as well as current
in developing countries, it is traumas and daily stressors, the Centre for
essential to consider the inherent the Study of Violence and Reconciliation
stressors and daily traumas in these (CSVR) developed a contextually
environments. appropriate psychosocial framework for
• To assist with the psychosocial the rehabilitation of individuals who have
impacts due to torture, an evidence- been affected by torture. Method: To test
based, contextually appropriate the efficacy of this framework, a quasi-
psychosocial rehabilitation experimental study was conducted with
framework has been developed by torture survivor clients of the CSVR who
the Centre for the Study of Violence met the 1985 United Nations Convention
and Reconciliation. Against Torture (UNCAT) definition. A
• Following a 3-month intervention comparison group of clients (n=38) was
based on this psychosocial initially included on a waiting list and
framework, torture survivors’ thereafter received treatment, whilst the
anxiety and functioning improve, treatment group of clients (n=44) entered
despite harsh contextual realities. straight into treatment. Results: Baseline
• However, ethical complexities t-test comparisons conducted on 13
and high levels of participant outcome indicators revealed significantly
attrition during longer therapeutic better initial psychological health and
intervention present challenges functioning of clients in the treatment group
T O RTU R E Vo lu m e 2 8 , Nu m be r 1 , 2 0 1 8
to experimental endeavours than those in the comparison group, with
designed to test the efficacy of the moderately large differences on PTSD,
rehabilitation framework. trauma and anxiety, and strong difference in
depression scores. Three-month follow-up
comparisons using the conservative
Wilcoxon test revealed significantly greater
*) Centre for the Study of Violence and Reconcilia- improvement on the functioning and anxiety
tion (CSVR), South Africa indicators of the treatment group relative
**) Wits School of Governance, University of the
to the waiting-list comparison group (odds
Witwatersrand, South Africa
Correspondence to: ddixpeek@csvr.org.za ratios = 2.49 and 2.61 respectively). After a35
SCIENTIFIC ARTICLE
further three months, when treatment was presents this framework and describes a
based on the CSVR framework for both quantitative study designed to examine
groups, fewer than half the respondents the effectiveness of its use for torture
remained in the study (n=20 in the rehabilitation.1
treatment group; n=16 in the comparison
group), and the Wilcoxon repeated measures Torture and its consequences
test results on changes since baseline were Torture is a gross human rights violation
counter-intuitive: for these remaining clients, that distresses the individual, family,
there were now more significant outcome community and society at large. Despite
improvements for the comparison group a number of international conventions
than for the treatment group. However, prohibiting torture and cruel, inhuman and
the relative odds ratios for the groups degrading treatment (CIDT), torture is
were not significant for these indicators. still practised in more than 140 countries
Furthermore, the clients who dropped out internationally, and still widely practised in
from the treatment group had shown overall Africa where it has been criminalised in only
improvement in their psychological health 10 countries (Amnesty International, 2014).
and functioning in the initial three months Sub-Saharan Africa hosts the largest number
of the study, whereas those who dropped of refugees internationally, with South
out from the comparison group had shown Africa receiving most of the asylum seekers
improvements on fewer indicators. Thus, in Africa (McColl et al., 2010; UNHCR,
the research findings on the efficacy of the 2015). Many of these people are likely to
framework are inconclusive. Discussion: have been tortured in their country of origin
We suggest that this inconclusiveness can or in transit (McColl et al., 2010). Within
be explained by the severe challenges South Africa, current victims of torture
and ethical complexities of psychosocial include youth in conflict with the law, non-
research on vulnerable groups. The study nationals, and people who are in the wrong
highlights the serious problem of attrition place at the wrong time (Bantjes, Langa, &
of participants in the treatment programme Jensen, 2012; Langa, 2013).
which affected the overall study, and which The consequences of torture may be
may explain findings that at first appear categorised broadly as physical, psychological
counter-intuitive. and social. The physical consequences
may be complicated by the psychological
Introduction consequences (Quiroga & Jaranson,
Continuing traumas, daily stressors and 2005). Similarly, torture-related mental
T O RTU R E Vol u m e 2 8 , N um be r 1, 2 01 8
trauma reactions from past traumas are health problems can cause physical and
characteristic of torture survivors in social problems which impact on both the
South Africa. Consequently, in 2013, personal and social functioning of survivors
the Centre for the Study of Violence
and Reconciliation (CSVR) based in
Johannesburg, designed a contextually
appropriate, evidence-based psychosocial 1
While the intervention was named a “model”,
framework for guiding the long-term due to the multi-modal nature of the document,
it was felt to be more representative to call it a
rehabilitation of individual survivors of
multi-modal framework for the rehabilitation of
torture (Bandeira et al., 2013). This paper torture survivors.36
SCIENTIFIC ARTICLE
(Baird, Williams, Hearn, & Amris, 2016). Although the South African Constitution
The physical sequelae of torture include (Republic of South Africa, 1996) and the
pain - often chronic, disability and medical Refugee Act (Republic of South Africa,
conditions (Harlacher, Nordin, & Polatin, 1998) provide basic civil and political
2016; Jørgensen, Auning-Hansen, & Elklit, rights such as free basic healthcare,
2017; Patel, Kellezi, & Williams, 2014). access to education and employment to
The psychological consequences refugees and asylum seekers regardless
of torture are often viewed in terms of of nationality and legal status, in reality
posttraumatic stress disorder (PTSD) these constitutional rights may be denied
and major depressive disorder (MDD) (Bandeira, 2013; Higson-Smith, 2013;
(Harlacher et al., 2016; Higson-Smith, Langa, 2013; Patel et al., 2014; Quiroga
2013). Lesser acknowledged psychological & Jaranson, 2005). Refugees and asylum
consequences include cognitive impairment, seekers experience high levels of crime
decreased functioning, sleep disturbances, and violence, xenophobia and exploitation
memory problems, attentional deficits and (Bandeira, Higson-Smith, Bantjes, & Polatin,
anger. Co-morbid psychiatric conditions 2010; Higson-Smith, 2013; Langa, 2013;
include depression, suicide, psychosis and Mohamed, Dix-Peek, & Kater, 2016), and
substance abuse (Bandeira, 2013; Quiroga, the South African asylum-seeking process
2017; Quiroga & Jaranson, 2005). has been associated with inconvenience,
The social consequences of torture cost and distress (Higson-Smith & Bro,
impact on the social wellbeing of the 2010; Langa, 2013). Continuing traumas
survivor. These effects include the loss of threaten the survival of many refugees and
“employment, status, family and identity” asylum seekers through ongoing threats
(Higson-Smith, 2013, p.165), separation from the police, government officials and
from loved ones (Higson-Smith, 2013; community members, and through domestic
Quiroga & Jaranson, 2005), the loss of violence, sexual violence and xenophobia
functioning and safety, and loss of cultural (Higson-Smith, 2013; Mohamed et al.,
and community connections (Higson- 2016). Such traumas “may influence the
Smith, 2013). way that survivors respond or adapt to
their precarious circumstances, but it is the
Living in contexts of continuing threat circumstances themselves that produce and
and daily stress maintain the client’s psychological state”
Vulnerability to mental health challenges (Higson-Smith, 2013, p. 166). Fear, anger
has been linked to pre-migratory exposure and distress, emotional collapse, helplessness
T O RTU R E Vo lu m e 2 8 , Nu m be r 1 , 2 0 1 8
to war trauma and torture, the migration and hopelessness (Bandeira, 2013; Kaminer
process itself, and the post-migratory & Eagle, 2010) are associated with daily
stressors of host countries which include stressors of documentation problems,
poverty and inadequate housing, and concerns over the health and schooling of
difficulties with asylum procedures family members, accommodation problems,
(Bogic, Njoku, & Priebe, 2015; Buhmann, unemployment, poverty, loss of social and
Mortensen, Nordentoft, Ryberg, & material support, ostracism and lack of
Ekstrøm, 2015; Jaranson & Quiroga, security (Bandeira et al., 2010; Higson-
2011; Jørgensen et al., 2017; Stammel et Smith, Mulder, & Masitha, 2007; Miller &
al., 2017). Rasmussen, 2010).37
SCIENTIFIC ARTICLE
Research on treatment approaches for and educational groups (Phaneth, Panha,
torture survivors Sopheap, Harlacher, & Polatin, 2014).
There are few scientific research studies Furthermore, the literature reviewed indicates
on the treatment of torture survivors as a strong prevalence of European and North
clinicians are inclined to prioritise direct American studies on the rehabilitation of
services to clients over research processes. torture survivors, with few outcome studies
Ethical concerns of differential treatment based in Africa. There is clear need for
of clients in control trials (Jaranson & scientific/ experimental research in this area
Quiroga, 2011; Stammel et al., 2017), the of work in an African context.
expense of scarce resources of rehabilitation
programmes (Bandeira, 2013), and The CSVR multi-modal framework for
generalisability of study results (Pérez-sales, the psychosocial rehabilitation of
Witcombe, & Otero Oyague, 2017) are individual survivors of torture
among the challenges of outcome studies. Given the dire contextual realities in which
The few experimental or quasi- many torture survivors live, research on
experimental designs on torture survivors the effectiveness of treatment frameworks
are usually affected by small sample sizes, needs to include psychological and social
the lack of control groups (Jaranson & health as consequences of torture (Patel,
Quiroga, 2011) and instruments with Kellezi, & Williams, 2014) in addition to the
limited validity and reliability often focused usual consequences of PTSD and MDD
only on improvement in PTSD and MDD (Bandeira, 2013; Higson-Smith, 2013).
(Jaranson & Quiroga, 2011). Meta-analyses Accordingly, the Centre for the Study
of randomised control trials illustrate of Violence and Reconciliation (CSVR)
improvements of generally small effect developed a multi-modal guiding framework
sizes in PTSD and depression when using for the rehabilitation of individual torture
Cognitive Behavioural Therapy (CBT) survivors that takes into account their lived
and Narrative Exposure Therapy (NET), realities of continuing traumas and ongoing
with moderate improvement on follow-up daily stressors (Bandeira et al., 2013).
(Patel et al., 2014). However, exceptional The development of the multi-modal
experimental studies do exist, with substantial CSVR model, hereafter referred to as the
improvements found using the Common CSVR framework, was based on a literature
Elements Treatment Approach, compared search, analysis of intervention process notes
to the less effective Cognitive Processing of CSVR clinical staff, and a Delphi process
Therapy (Weiss et al., 2015). Quasi- for expert consensus on the most severe
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experimental and outcome research on the impacts of torture and the most appropriate
rehabilitation of torture survivors provides methods of torture intervention in a South
further support for CBT (Halvorsen & African context. There was consultation
Stenmark, 2010; Neuner et al., 2010) and between the research and clinical teams
NET (Dibaj, Overaas Halvorsen, Edward on the categorisation of the impacts, their
Ottesen Kennair, & Inge Stenmark, 2017; assessment and the most appropriate
Hansen, Hansen-Nord, Smier, Engelkes- intervention approaches. As a result, the
Heby, & Modvig, 2017), culturally tailored CSVR framework comprises the 18 most
health promotion intervention (Berkson, severe impacts of torture (14 after grouping
Tor, Mollica, Lavelle, & Cosenza, 2014) the impacts) in contexts such as those found38
SCIENTIFIC ARTICLE
in South Africa, and the most appropriate Given the reality of unsafe
intervention strategies associated with each circumstances, it may be appropriate that
(Table A - 1, numbered alphabetically per clients’ reactions include paranoia and
area). Aspects of trauma-focused CBT hypervigilance. The clinical approach
(TFCBT), NET, dialectical behavioural outlined in the framework uses reality
therapy, supportive therapy, problem solving testing, dealing with perceived threats,
and solution-focused therapy underpin safety planning, skills development
therapeutic interventions in the framework, and symptom management to assist
with an emphasis on empowerment. As such, clients to reduce repeated victimisation
the framework is considered to be multi- and increase their skills to ensure their
modal and informed by mutiple theories. continued safety.
Many centres adopt a multi-disciplinary, • Continuing traumas while dealing with
multi-modal, or “common-sense” approach past traumas and torture experiences:
to psychosocial interventions (Pérez-sales The framework provides guidelines
et al., 2017) in which the therapist chooses on how clinicians may help clients
from different modalities according to understand their reactions to past
the needs of the torture survivors. These traumas and how these reactions relate
approaches provide a more meaningful to their responses to the ongoing traumas
personalisation of the survivors’ needs, that may affect them.
which together with a clear therapeutic • Managing relationships with service
relationship and culturally tailored goals, providers, family members and
may be more appropriate than a rigid community members:
“one-size-fits-all” therapeutic model. The framework provides guidelines
While there are several multi-modal on how clinicians may assist clients to
treatment approaches for assisting torture deal with their emotional reactions to
survivors (Drozdek, 2015; Stammel et al., traumas, and to build the social capital
2017), the CSVR framework offers clearly necessary to maintain relationships and
articulated therapeutic guidance relevant obtain services, for example, medical and
to South African and developing contexts. legal assistance or documentation from
For example, it provides clear outlines the Department of Home Affairs.
for the role of clinicians in attending to
the therapeutic needs of clients, and for Research design
the “core business” of the CSVR clinical The design of the current research is
team, both essential therapeutic elements described as quasi-experimental. It
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for maintaining therapeutic boundaries, comprises two groups of participants,
empowering clients and increasing their both groups observed over six months
resilience. Although it is assumed that what but differentiated according to when their
the client brings to therapy will be the participants approached the Centre, when
focus of the session, the CSVR framework they commenced treatment with the CSVR
provides guidelines on how to assist clients framework, and the duration of treatment
when certain needs arise, for example: based on the CSVR framework (Figure 1).
• Lack of safety, repeated victimisation The ‘treatment’ group comprised clients
and high levels of violence in a South who came for counselling between July 2014
African context: and December 2015 and were treated based39
SCIENTIFIC ARTICLE
on the CSVR framework for six months. The for the comparison group. Secondly, it was
‘comparison’ group comprised clients who hypothesised that there would be greater
came for counselling at the Centre between improvement in the psychological and
January and June 2014 and were placed on functioning measurements from T1 to T3 for
a 3-month ‘Waiting list’ condition before the treatment group than for the comparison
commencing three months of treatment group, as the treatment group received
based on the CSVR framework. treatment based on the CSVR framework
Psychological wellbeing and functioning for six months, while the comparison group
were measured three times: participants received this treatment for three months
in the treatment group were measured only following the 3-month waiting list
before the start of the CSVR intervention condition.
treatment (T1), three months after the start
of CSVR framework treatment (T2), and Methods
after a further three months of the CSVR Procedure
framework treatment (T3); participants in The treatment group received treatment
the comparison group were measured before based on the CSVR framework for six
the start of a 3-month waiting period (T1), months; the comparison group received an
at the end of the 3-month waiting period initial 3-month waiting condition before
(T2), and then three months after the start receiving treatment based on the CSVR
of the CSVR framework treatment (T3) (see framework for three months.
Figure 1). In the 3-month waiting condition, a
Written informed consent was obtained clear waiting list management took place. A
from all participants. Ethical clearance trained trauma professional phoned clients
was provided by an internal CSVR ethics in the comparison group every two weeks
committee as well as by external experts in to check that they still wanted to come
the violence and/or torture field, including a for counselling, and to refer clients for
lecturer at a Johannesburg-based university medical, legal and humanitarian assistance
and two partners working at international if necessary. This condition compared with
NGOs providing services to survivors of clients who went straight into treatment
torture. This approach to ethical clearance using the CSVR framework (see The
was necessary as there is no overarching CSVR multi-modal framework for the
national ethics body in South Africa, and psychosocial rehabilitation of individual
CSVR is not affiliated with a university. survivors of torture, on page 37).
Emergency cases in both groups (clients
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Hypotheses experiencing psychosis, who were suicidal
As the treatment group received specialised or other emergencies) were contained
counselling for the first three months and referred for psychiatric assistance at a
and the comparison group received less local hospital, or for medication from the
specialised communication (as part of the consultant psychiatrist at the CSVR.
waiting list protocol) for their first three Baseline measures were carried out
months, it was hypothesised that there using the same instrument at the start of the
would be greater improvement in the CSVR treatment condition of the treatment
psychological and functioning measurements group, and at the start of the waiting time
from T1 to T2 for the treatment group than condition of the comparison group (T1). A40
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second set of measures was carried out three i.e. six months after commencement of the
months after commencement of the CSVR CSVR condition of the treatment group, and
condition of the treatment group, and three three months after commencement of the
months after the start of the waiting time CSVR condition of the comparison group
condition of the comparison group (T2). A (T3) - see Figure 1.
third set of measures was carried out three Every two weeks, clinicians participated
months after the second set of measures, in supervision sessions which focused
T O RTU R E Vo lu m e 2 8 , Nu m be r 1 , 2 0 1 8
Figure 1: Study procedure41
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both on fidelity to the framework as well (waiting list) baseline (T1), were included in
as guidance with therapeutic concerns. the waiting list group, and had also
Supervisors ensured that clinicians followed completed a treatment baseline (T2). At T3,
the framework and concurrently documented 16 participants from this group remained,
which aspects of the framework were utilised having completed the waiting list baseline,
using a fidelity checklist. Any difficulties with treatment baseline and 3-month follow-up
the implementation of the framework were assessment, and these 16 were included in
discussed with the researchers and indicated the follow-up study (Figure 1).
in the fidelity checklist. Assessment measures: The assessment
tools used for all clients at T1, T2 and T3
Participants included the Harvard Trauma
All participants were selected according Questionnaire (HTQ) measuring
to the 1985 UNCAT definition of torture posttraumatic stress disorder (PTSD),
(United Nations General Assembly, 1985) clients’ self-perception of functioning and
and were over 18 years old. No substantial overall trauma (Harvard Program in
historical events were noted for the 6-month Refugee Trauma, 1992), the Hospital
period that separated the groups. Anxiety and Depression Scale (HADS)
Participants in the treatment group: The measuring anxiety and depression
participants in the treatment group were (Zigmond & Snaith, 1983), the De Jong
selected from clients who approached the Gierveld Loneliness Scale measuring
CSVR between 1 July 2014 and 30 December clients’ emotional loneliness and social
2015. Over this period, 197 clients were loneliness (de Jong Gierveld & Van Tilburg,
screened, and 24 clients excluded based on the 2006), the number of areas of pain in the
UN torture definition, and a further 129 body,2 and management of aspects of
clients excluded due to incomplete T1 or T2 functioning.3 Reliability measures are
outcome measures. Thus 44 clients had presented in Table A - 2.4
completed both their baseline assessment and a All assessments were administered by
three-month follow-up and were included in trained psychologists or social workers.
the treatment group. Of this group, 20 Translation through interpretation was
completed their six-month follow-up and were
included in the follow-up study (Figure 1).
Participants in the comparison group: The 2
The total number of areas of pain was based on
participants in the comparison group were the areas of pain in the body pointed out or indi-
selected from clients who approached the cated verbally.
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3
For management of aspects of functioning, four
CSVR from January to June 2014. Over this
Likert-type scaled questions were adapted from
period, 87 clients were screened, 66 of whom the International Classification of Pain and
met the inclusion criteria for the waiting list Disability (ICF) (WHO, 2001): Family-related
group, with 21 excluded as they had not stressors, External stressors (excluding family-
related stressors), Managing situations that made
experienced torture according to the UN
the client angry, and Psychological or emotional
torture definition. A further 28 clients were functioning. Scale responses ranged from manag-
then excluded as they had not completed a ing very poorly, to managing very well.
follow-up assessment, leaving 38 clients as
4
As Cronbach’s coefficient α is correlated with the
number of items in the scale, average inter-item
participants in the comparison group. These
correlations are also presented as their values are
38 clients had completed a comparison independent of scale length (Table A - 2).42
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provided to clients in the main languages of Finally, post hoc analyses were used
clients who come to the clinic. These include to examine the effects of the higher than
French, Swahili, Amharic, Somali and expected attrition rate of respondents of the
Lingala. All interpreters were trained on the two groups who dropped out of the study
assessment tools. after T2, i.e. during the 3-month counselling
Analysis methods: Initially the baseline period between T2 and T3. This comparison
(T1) psychological and functioning was deemed necessary to examine whether
measurement means of the treatment and a systematic bias may have been added to
comparison groups were compared using the data at T3, should the participants who
t tests and Cohen’s d effect sizes, and left the comparison group after T2 differ
categorical variables compared via the Chi from the participants who left the treatment
square test. Thereafter the mean changes group after T2. Such a situation would bias
of the two groups were compared for the the samples and the results of the T1-T3
first three months (T1 to T2) and then comparison relevant to the second hypothesis.
for the six month period (T1 to T3) via This analysis was a simple examination of
mixed analysis of variance (ANOVA).5 In the demographics, as well as of the direction
both cases, the ANOVA interaction effects of the mean differences for each scale from
were examined for evidence of a significant T1 to T2 for the participants in each group
differential pattern in the mean scores across who dropped out after T2. No other post hoc
the time periods depending on the group, analyses on the results are presented.
and partial eta-squared effect sizes were used
as measures of the strength of differences. Results
Where necessary, the Scheffé post hoc test Table 1 shows details of the participant
was used to locate significant differences characteristics for both groups.
between means. In view of the multiple Approximately half of the participants were
violations of the assumptions of the mixed male, fewer than 10% were South Africans,
ANOVA analyses, the conservative non- and the dominant groups were from Congo
parametric Wilcoxon signed-ranks test was (DRC), Ethiopia and Somalia. Over half
used on the separate groups. In addition, the were living with a partner, spouse, family
odds ratio was used to indicate effect sizes member or friend, approximately 80% were
for the individual groups, and for assessing either asylum seekers or refugees, and fewer
the odds of improvement in the treatment than half of the participants of each group
group relative to the comparison group.6 had experienced torture within the past year
in each group (a third of the comparison
T O RTU R E Vo lu m e 2 8 , Nu m be r 1 , 2 0 1 8
versus 39% of the treatment group). Before
5
Ideally, mixed multivariate Analyses of Variance the torture, 5% or fewer were unemployed
(MANOVA) would be computed on the compo- whereas approximately three-quarters or
nents of the scales to detect multivariate response more were unemployed at the start of the
patterns, while controlling the family-wise Type 1
study. The ages of the participants ranged
error rate with greater power to detect differences.
However, the sample sizes were small, and in all from 18 to 72 years, with mean age in the
instances, assumption violations of the multivari- mid-thirties (M=36.20 years, SD=10.35
ate analyses mitigated against the MANOVA tests. years for the treatment group, and M=34.82
6
This exploratory approach was undertaken whilst
years, SD=8.68 years for the comparison
recognising that the family-wise Type 1 error in-
creases with multiple statistical tests. group). The treatment group had a higher43
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Table 1: Demographics of treatment and comparison groups
Treatment Comparison
Demographics
group (n=44) group (n=38)
n % n % p^
Gender Female 22 50% 16 42% 0.47
Male 22 50% 22 58%
Nationality Burundi 2 5% 1 3% 0.98
Congolese (DRC) 15 34% 13 34%
Eritrean 0 0% 4 11%
Ethiopian 8 18% 13 34%
Somali 12 27% 3 8%
South African 1 2% 3 8%
Zimbabwean 2 5% 0 0%
Other * 4 9% 1 3%
Marital status Currently married 24 55% 8 21% 0.01
Divorced/separated 3 7% 4 11%
Never married 13 30% 18 47%
Widowed 4 9% 7 18%
Missing 0 0% 1 3%
Currently living Living alone/strangers/shelter 14 32% 7 19% 0.14
Living with family/ children 16 36% 5 13%
Living with friends 7 16% 10 26%
Living with spouse/ partner 4 9% 4 11%
Other 0 0% 4 11%
Missing 3 7% 8 21%
Legal SA status Asylum seeker/ refugee 37 84% 30 79% 0.78
Citizen 2 5% 3 8%
Undocumented 4 9% 1 3%
Missing 1 2% 4 11%
Pre-torture employment Minor/ student 5 11% 5 13% 0.83
Unskilled labour/ semi-skilled 22 50% 21 56%
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Skilled/ professional 14 32% 10 26%
Unemployed 2 5% 1 3%
Missing 1 2% 1 3%
Current employment Minor/ student 0 0% 2 5% 0.39
Unskilled labour/ semi-skilled 8 18% 3 8%
Skilled/ professional 3 7% 2 6%
Unemployed 32 73% 31 82%
Missing 1 2% 0 0%44
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Treatment Comparison
Demographics
group (n=44) group (n=38)
n % n % p^
Education No schooling 4 9% 1 3%45
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Table 2: Trauma types experienced by respondents of the comparison and treatment groups
Treatment group Comparison group Odds ratio: Treatment/
(n=44) (n=38) Comparison
OR Fisher exact
n % n % test
(p)
Torture/ CIDT 44 100% 38 100% - -
Witness to trauma 31 70% 30 79% 0.64 0.27
Assault 25 57% 28 74% 0.47 0.09
Bereavement/ traumatic bereavement 16 36% 21 55% 0.46 0.07
Armed robbery 18 41% 18 47% 0.77 0.36
Xenophobia 12 27% 17 45% 0.46 0.08
Mugging 5 11% 13 34% 0.25 0.02
War 15 34% 13 34% 0.99 0.59
Hostage/ kidnapping/ abduction 9 20% 8 21% 0.96 0.58
Rape/ attempted rape/ sodomy 14 32% 6 16% 2.49 0.08
Motor vehicle accident 2 5% 5 13% 0.31 0.16
Hijacking 5 11% 5 13% 0.85 0.53
Relationship/ domestic violence 2 5% 5 13% 0.31 0.16
that three of the four initial coping or Comparison of the changes in the psychological
managing scores of the treatment group and functioning measures across the first three
are significantly better than those of the months (T1 to T2) for each group: Based on
comparison group, and the PTSD, trauma, the direction of the differences between each
anxiety and depression scores are lower of the T1-T2 pairwise means for the
(α=.05). The effect sizes of these differences treatment and the comparison groups
are moderately large (Cohen’s d with considered separately, all 13 of the pairwise
magnitude at least .5), with the exception differences of the treatment group are in the
of the strong difference in depression scores ideal direction of improved psychological
of the two groups (t(79)=3.36, p46
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assumption violations for the T1 or T2 scores 2.61 for anxiety means that the clients in
of 7 of the 13 ANOVA comparisons, the the treatment group reduced their anxiety
T1-T2 comparisons of the separate groups 2.61 times more than the clients in the
were re-examined using the conservative comparison group did.
non-parametric Wilcoxon signed-ranks test There thus appears to be partial support
with Z score conversion for large sample for the expectation of greater improvement
sizes and asymptotic significance, and the in psychological health and functioning
odds ratio (OR) used to indicate effect size from T1 to T2 for the treatment group
(Table 3). relative to the comparison group. We
The Wilcoxon results of the treatment therefore conclude, conservatively, that
group show seven significance changes there is insufficient statistical evidence
(emotional and total loneliness, external for overall support of the first hypothesis
stressors, functioning, trauma, anxiety and of the research and we instead discuss
areas of pain), all with odds ratios greater the significant T1-T2 differences on the
than 1 (Table 3). By contrast, there are two individual indicators, specifically differences
significant T1-T2 differences (depression on the indicators of functioning and anxiety.
and areas of pain) in the comparison Comparison of the changes in the
group. For the treatment group, the odds of psychological and functioning measures across
improvement relative to non-improvement the three time periods (T1-T3) for each group:
are greater (odds > 1) for 9 of the indicators The comparisons from T1 to T3 are based
of psychological health and functioning, on substantially reduced sample sizes owing
compared to 5 indicators for the comparison to attrition of participants in the two groups
group. Furthermore, ratios of the odds after the second set of measures. Under half
for the treatment group relative to the the respondents remained after T2 (45% or
comparison group computed per indicator 20 of the 44 participants in the treatment
variable show OR values greater than 1 group, and 42% or 16 of the 38 participants
for most indicators (emotional and total in the comparison group).
loneliness, the coping indicators of external Based on the mixed ANOVA tests, there
stressors and psychological difficulties, the is no evidence of significant interaction
HTQ scales of PTSD, functioning and effects that would show a difference in the
trauma, the HADS anxiety scale, and areas changes of scores over time depending on
of pain - Table 3). Thus, for these indicators, the group, and the magnitude of all effect
members in the treatment group improved sizes, as measured by partial eta squared
their psychological health and functioning values, are negligible to weak. However,
T O RTU R E Vo lu m e 2 8 , Nu m be r 1 , 2 0 1 8
from T1-T2 more than members in the significant main effects across time, in the
comparison group did. However, based on direction of increased psychological health
the Fisher Exact Probability test (1-tailed, and functioning, were found for coping
α=.05), the odds ratios are only significant with anger, the HTQ, the HADS, as well as
for the HTQ functioning scale and for the for number of areas of pain. In particular,
HADS anxiety scale. The OR value of 2.49 based on post hoc Scheffé comparisons,
for functioning means that the clients in the measures of self-perception of functioning,
treatment group improved their functioning depression and number of areas of pain
2.49 times more than the clients in the improved significantly from one time to the
comparison group did; the OR value of next. As for the T1-T2 comparisons, the47
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Table 3: Wilcoxon signed-rank test and odds ratio effect sizes for T1-T2 repeated measures for
treatment and comparison groups
Odds ratio:
Treatment group Comparison group
Treatment/
(n=44) (n=38)
Comparison
Indicators
Fisher
Odds Odds exact
Z p^ Z p^ OR
^^ ^^ test
(p)
Connection to Emotional 2.06 0.04 * 1.32 0.10 0.92 1.06 1.25 0.40
others loneliness
Social loneliness 0.98 0.33 1.16 0.13 0.89 1.24 0.94 0.53
Total loneliness 2.11 0.03 * 1.29 0.03 0.98 1.09 1.18 0.44
Coping or Angry situation 1.43 0.15 0.83 0.49 0.63 0.84 0.98 0.58
managing
Family related 0.59 0.56 0.67 1.59 0.11 0.87 0.77 0.38
stressors
External stressors 2.06 0.04 * 1.06 0.07 0.94 0.69 1.54 0.23
Psychological 1.34 0.18 0.97 0.58 0.56 0.79 1.23 0.42
difficulties
Harvard PTSD 1.70 0.09 1.21 0.27 0.79 1.10 1.10 0.52
trauma
questionnaire Functioning 2.57 0.01 * 1.71 0.39 0.69 0.68 2.49 0.04 *
Trauma 2.28 0.02 * 1.56 0.02 0.99 0.79 1.97 0.10
Hospital Anxiety 2.83 0.01 ** 1.56 0.48 0.63 0.60 2.61 0.04 *
anxiety and
depression Depression 0.99 0.32 0.87 3.17 0.01 ** 1.79 0.49 0.10
scale
Pain Number of areas 2.44 0.01 * 1.23 2.26 0.02 * 0.94 1.31 0.36
of pain
T O RTU R E Vol u m e 2 8 , N um be r 1, 2 01 8
* p < .05; ** p < .01
^ denotes the asymptotic significance value (2-tailed) for Wilcoxon Z for large samples
^^ tied changes were randomly distributed in equal proportions to positive and negative changes, rendering the
odds ratio more conservative than the Z score
T1-T3 comparisons were re-examined using psychological health and functioning,
the conservative non-parametric Wilcoxon exceptions being social loneliness and
signed-ranks test on the separate groups, coping with external stressors. However,
owing to violations of ANOVA assumptions. counter-intuitively, the results of the
For both groups, most of the outcome Wilcoxon signed-ranks tests on the T1-T3
means changed in the direction of improved comparisons computed on the separate48
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groups revealed more significant T1-T3 In Table 4, the means for each scale
improvements for the comparison group are presented for those members of the
than for the treatment group. For the treatment group and the comparison group
comparison group, 7 of the 13 outcome who left the programme after the second set
measures improved significantly from T1 of measures.9 The outcome measures with
to T3 (α=.05), (coping with anger, the T1-T2 changes in the direction of improved
HTQ measures of PTSD, functioning and psychological health and functioning are
trauma, the HADS measures of anxiety and indicated with a tick ().10
depression, and areas of pain), compared to The members of the treatment group
only 1 of the 13 outcome measures (areas of who left the programme after T2 had
pain) for the treatment group. Nevertheless, improved their mean scores on all 13
none of the odds ratios computed via measures at T2. By contrast, the members
the ratio of odds for the treatment and of the comparison group who left the
comparison groups per indicator variable programme after T2 had improved their
are significant based on the Fisher mean scores on fewer than half (6 out of 13)
Exact Probability test (α=.05). Thus, of the measures (social and total loneliness,
although there are more significant T1-T3 family related stressors, psychological
improvements in the comparison group difficulties, depression and areas of pain),
than in the treatment group, the magnitude a significant difference in percentages
of these improvements is not sufficient to (p=.002). Thus, participants in the treatment
render the odds of the improvements in group who left the programme at T2 had
the comparison group significantly greater improved their overall psychological health
than the odds of the improvements in the and functioning, whereas the participants
treatment group. in the comparison group who left the
However, the counter-intuitive Wilcoxon programme at T2 had not shown this
test results on the T1-T3 comparisons, overall level of improvement. After T2,
whatever their magnitude, need to be the treatment group appears to have been
addressed. A possible explanation is weakened by the loss of members who
presented in a post hoc set of comparisons had improved health after three months,
using a basic analysis of attrition after T2. while the comparison group had not lost
Comparison of participants in each group overall improvers. This differential pattern
who dropped out after T2: Based on the of attrition between the groups may explain
Chi square test for between-group the counter-intuitive findings of greater
comparisons, there is no evidence of improvement from T1-T3 of the remaining
T O RTU R E Vo lu m e 2 8 , Nu m be r 1 , 2 0 1 8
significant differences in the demographic members of the comparison group
characteristics of participants who compared to the remaining members of the
dropped out of the treatment group after treatment group.
T2 versus those who dropped out of the
comparison group after T2. However,
comparison of the T1-T2 changes in the 9
As tests of significance are reserved for a future
psychological health and functioning in-depth article on attrition, this analysis does
measures of these two groups suggests not indicate significance or effect size.
10
In each comparison, the direction of the means is
that there may be a differential pattern of
based on the difference in the pairwise means of
attrition between the groups. individuals.49
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Table 4: Mean scores from T1-T2 of participants who left the comparison and treatment groups
after T2
Participants who left after T2:
those who left from those who left from
the treatment group the comparison
(n=24) group (n=22)
Indicators Mean T1-T2 Mean T1-T2
T1 2.83 ü 2.48
Emotional loneliness T2 2.52 2.50
Connection to T1 2.87 ü 2.52 ü
Social loneliness T2 2.75 2.32
others
T1 5.70 ü 5.00 ü
Total loneliness T2 5.17 4.82
T1 2.61 ü 2.14
Angry situation T2 2.67 2.00
T1 2.23 ü 1.60 ü
Family related stressors T2 2.43 2.21
Coping or
managing T1 1.87 ü 1.90
External stressors T2 2.33 1.86
T1 2.35 ü 2.10 ü
Psychological difficulties T2 2.74 2.24
T1 2.54 ü 2.76
PTSD T2 2.33 2.91
Harvard T1 2.48 ü 2.60
trauma Functioning T2 2.25 2.82
questionnaire
T1 2.50 ü 2.67
T O RTU R E Vol u m e 2 8 , N um be r 1, 2 01 8
Trauma T2 2.28 2.83
T1 1.71 ü 1.86
Hospital Anxiety T2 1.31 1.89
anxiety and
depression T1 1.57 ü 1.89 ü
scale Depression T2 1.28 1.63
T1 1.96 ü 3.23 ü
Pain Areas of pain T2 1.83 2.3250
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Discussion assumptions required for parametric
The research was designed to test the statistical analyses. Attrition created a
efficacy of the CSVR psychosocial further problematic effect in our study as
intervention framework using a sample of the treatment group clients who dropped
torture survivors, almost all of whom were out of the study after T2 showed greater
asylum seekers, refugees and undocumented overall improvement in their psychological
persons in a South African environment health and coping from T1 to T2 than the
filled with daily stressors and continuing comparison group clients who dropped
traumas. These individuals were found to out of the study after T2. This differential
have clinical baseline scores on PTSD, attrition effect may have biased the longer-
depression, anxiety and low levels of term comparison of the mean scores
functioning, which may be explained, at from T1 to T3 (the second hypothesis of
least in part, by their history of torture the study), creating paradoxical results.
which severely impacts psychological and Thus, our main finding pertaining to the
psychiatric wellbeing (Bandeira et al., 2010; hypotheses on the efficacy of the CSVR
Higson-Smith, 2013; McColl et al., 2010; framework is that we have not found
Patel et al., 2014; Quiroga & Jaranson, sufficient evidence to warrant the efficacy
2005). The CSVR framework is designed of the framework, owing mainly to several
to address the complexity of the past severe challenges inherent in research of this
traumas exacerbated by contextual realities nature. It may be fairer to conclude that
of a hostile South African environment the research results on the efficacy of the
(Bandeira, 2013; Bandeira et al., 2013). framework are inconclusive.
However, there are several interesting
Efficacy of the CSVR framework results in the research. Firstly, improvement
The assessment of the efficacy of the CSVR in the psychological wellbeing and
framework was based on the expectation functioning of the clients of both groups
of a long-term differential effect when an from T1 to T3 occurred despite the context
initial three-month waiting list condition of the lack of safety and continuing daily
was included, compared to when clients traumas of the torture survivor clients.
entered straight into treatment. The findings This result is consistent with the CSVR
of the research did not provide clear support framework’s prioritisation of empowerment,
for the hypotheses of greater improvement problem solving and trauma-related therapy.
in the psychological health and coping Secondly, after three months of treatment
indicators of the CSVR treatment group under the CSVR framework, there are
T O RTU R E Vo lu m e 2 8 , Nu m be r 1 , 2 0 1 8
than the waiting list comparison group. indications of clients’ improved connection
However, the results are complex and less to others. This result is encouraging within
than clear. the inherent mistrust, isolation and fear
The data gathered reflect the challenges as consequences of torture (Quiroga
of attempting rigorous quasi-experimental & Jaranson, 2005). Building trusting
quantitative research in the context of relationships after a torture experience
torture, using established measurement should be viewed as a long-term therapeutic
scales that were found to have lower than goal (as per the approach of the CSVR),
desirable reliability for our sample, and as torture often results in the annihilation
data that do not meet all the stringent of interpersonal trust (Bandeira, 2013;51
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Bandeira et al., 2013). Further research is CSVR treatment framework for the two
warranted on the prioritisation of a family groups, we found that the psychological
and group model or framework in the South health and functioning of members of the
African context to mitigate the isolation felt treatment group was somewhat better than
by the torture survivor, and the best way to that of the comparison group at baseline
reintegrate the torture survivor into trusting testing. The groups also differed on marital
familial, group and community relationships. status and education levels.
Thirdly, after three months in therapy, In addition to these baseline differences
clients appear to deal better with their past between the groups, the nature of the
traumas and torture experiences in the comparison group condition, i.e. the
context of unsafe situations, specifically in waiting list protocol, was not a true placebo
terms of increased functioning and reduced comparison as it offered a level of support
anxiety levels. to clients in the comparison group. The
We move now to discuss the main comparison group clients received support in
challenges of scientific research on trauma, telephone calls every second week, referrals
based on the lessons of this study. offered for legal, medical or humanitarian aid,
and assistance offered if they were psychotic,
Challenges of research on trauma rehabilitation suicidal or required other emergency
It is essential to conduct thorough research assistance. After three months of receiving
on the outcomes of torture rehabilitation this level of support, these waiting list clients
programmes that could improve the quality may well have felt somewhat better on a
of the services and care to torture survivors, psychological and functioning level than they
contribute to professional development in had at baseline. Indeed, the results of the
the field, and empower torture survivors comparison group clients showed significant
(Jaranson & Quiroga, 2011). Although improvement in their depression scores.
quantitative studies involving the principles However, despite the possible confounding
of randomised experimental design, sound effect of the waiting list condition, it is
sampling techniques, objective measures and an ethical necessity in the context of the
rigid statistical analysis are scientific ideals, vulnerability of torture survivors.
such criteria are, in reality, unattainable High levels of overall attrition are
in the complex and challenging world of expected in this population due to the
torture rehabilitation with its thorny ethical transient nature of tortured refugees in
considerations and limitations. Ethical South Africa who often need to move
compliance precludes randomised control to find employment or accommodation,
T O RTU R E Vol u m e 2 8 , N um be r 1, 2 01 8
group designs; instead, researchers of torture or due to safety concerns. Furthermore,
attempting scientific studies are restricted to many refugees and asylum seekers use the
quasi-experimental or outcome designs with CSVR for introduction to legal, medical
compromised internal validity. or humanitarian aid, and then terminate
We present the consequences of these contact with the centre. Although previous
research design restrictions in our research. CSVR reports indicate an attrition rate of
Although there was no apparent reason 21-44% of clients annually (Dix-Peek, 2012a,
for the groups to differ at baseline, and no 2012b), the current research indicates a
outstanding historical events occurring in much higher rate (75% or 129 of 173 clients
the time interval between the start of the in the treatment group, and 42% or 28 of52
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66 clients in the comparison group).11 The who improved their health may be evidence
high rate of attrition from screening to T1, of the preliminary success of the CSVR
referred to here as overall attrition, for both framework, although the sustainability of the
groups, but particularly for the treatment improvement is unknown.
group, is a clear limitation of the current The topic of attrition is planned as part
research. Contextual challenges of staffing of a future journal article.
changes within CSVR may have contributed
to clients not completing their baseline T1 or Conclusion
follow-up T2 assessments and the consequent The CSVR psychosocial framework for the
stark overall attrition for the treatment rehabilitation of torture survivors provides a
group. CSVR has attempted to mitigate the set of therapeutic guidelines in the context
high overall attrition through ensuring that of daily stressors, continuing traumas,
clients receive transport money to and from past torture and trauma events. It is also a
the office, conducting drop-out reports for framework designed for developing country
a better understanding of why clients stop settings where survivors live with lack of
coming for counselling, providing ongoing safety and extreme socio-economic concerns.
training with CSVR clinicians and monitoring Thus evidence-based research on the
and evaluation staff, and ensuring adherence efficacy of this framework is essential as a
to the monitoring and evaluation system. first step towards investigating its legitimacy
The high rate of attrition of clients after as “best practice” for torture survivors in
the initial three months of the programme developing countries. However, conducting
is also of great concern for the CSVR such research is often not prioritised due
rehabilitation endeavours as over half of to scarce financial and human resources,
the clients left the study after T2 (55% of practitioners who may not recognise the
the treatment group members and 58% need to prioritise outcome research over the
of the comparison group members). A “core” therapeutic and psychosocial work
rudimentary post hoc attrition analysis of the (Bandeira, 2013; Montgomery & Patel,
means of the outcome measures suggests 2011), attrition and small samples sizes,
that different patterns of attrition in the limited academic and research expertise,
comparison and treatment groups may and ethical concerns (Jaranson & Quiroga,
explain the counter-intuitive results from 2011). Our study has aimed to contribute to
T1-T3. The comparison group clients who a detailed understanding of the intricacies
left the programme at T2 showed limited and challenges of undertaking psychosocial
improvement in their psychological health research in the torture field. It highlights
T O RTU R E Vo lu m e 2 8 , Nu m be r 1 , 2 0 1 8
and functioning, while the treatment group the serious problem of attrition and offers
clients who left the programme at T2 several lessons for future studies.
showed improvement on all indicators. While
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