Cognitive Processing Therapy for Cognitive Processing Therapy for  Torture Survivors in Kurdistan, IraqTorture Survivors in Kurdistan, Iraq

Lessons From a Randomized Clinical TrialLessons From a Randomized Clinical Trial

Debra Kaysen,  Kristen Lindgren, & Shelly GriffithsDebra Kaysen,  Kristen Lindgren, & Shelly GriffithsUniversity of WashingtonUniversity of Washington

Paul Bolton, Judy Bass, Laura MurrayPaul Bolton, Judy Bass, Laura MurrayJohns HopkinsJohns Hopkins

Background  Treatment of Torture Survivors

Organized by Heartland Alliance

Operating in Kurdistan since 

December 2004

Providing mental health and 

psychosocial services to torture‐

affected persons

Established a rural network of 

paraprofessionals and physicians in 

ten of Iraq’s eighteen Governorates

2 years of qualitative and quantitative 

groundwork by Paul Bolton and Judy 

Bass at Johns Hopkins

How to treat PTSD & depression in Kurdistan?

There have been several trials of EST’s internationally.

Interpersonal therapy for depression has been used 

successfully in Africa.

TF‐CBT has also been used successfully in Africa.

No trials have been conducted in the Middle East.

CPT has been used successfully with Bosnian refugees in 

the US.

Background  Treatment of Torture Survivors

4 arm randomized clinical 

trial (n

= 500)

Cognitive Processing 

Therapy

Behavioral Activation

Supportive Counseling

Wait List Control

Introduction to CPT

Cognitive Behavioral Therapy

Uses cognitive restructuring and 

written exposure

2 sessions exposure

Typically 12 session protocol

CPT=26.6 hours written homework 

over 12 weeks

Conducted by clinicians with an 

MA, MSW, Ph.D., or M.D.

Training

2 trainers

11 community mental 

health workers

Supervisor

Cardiologist

8 days

Translator

Who to Train

CMHWs are trained physician assistants 

who also perform nursing and other 

clinical functions in primary health 

centers 

Previous CMHW training consisted of 5 

days training:

common mental health problems, 

(depression, anxiety disorders, and 

PTSD)

psychoeducation

counseling and social support skills

making treatment plans, engaging 

families, advocacy, and substance 

abuse 

Challenges Identified by the CMHW’s

A majority of clients are illiterate.

Challenge:  How to conduct homework assignments for 

therapy)

A majority of clients are illiterate.

Challenge:  How to conduct homework assignments for 

therapy

Solutions:  

Modify homework so that it does not have to be written

Have a literate family member help

Use audio recorders to record homework (recorders left at the clinic)

Use prompts to remember to make a mental note of homework (cell 

phone alarms, call to prayer)

Challenges Identified by the CMHW’s

Some barriers for female clients:

Challenge A: The sex of the CMHW may play a role

Solutions: Making all efforts to ensure that female clients are 

seen by female CMHWs; ensuring that when this is not 

possible, that the client is accompanied by someone else if 

possible.

Challenge B:  Some families may not allow them to see 

a CMHW at all

Solutions:  Efforts can be made to inform the family about the 

benefits of the client receiving services.

How to train

Iterative

Teach and then ask about how that 

works here

Have people explain the concepts back to 

you

Roleplay EVERY skill

Trainers model, trainees demonstrate, 

get feedback

Listen to roleplays with the translators

Use socratic dialogue

Review each session at the beginning and 

end

What to Train

Remove technical language and jargon

Socratic questions? Problematic 

thinking patterns? Maladaptive 

cognitions?

Even words like “understandable”

or “statement”

do not always 

translate

Make manual as simple and as concrete 

as possible

“You do 3 things during each 

visit…”

“Respect the steps”

What to Train

Limit homework

What’s essential?

What can be eliminated?

Changes for illiteracy

Balancing amount someone 

can remember with adequate 

practice

Use of naturally occurring cues

Using pictoral cues

Use of family and friends as 

helpers

Supervision structure is complex but critical

Complete form indicating which CPT 

skills they used, which they did not 

use, and why. 

Weekly supervision with CMHW’s. 

Uses chart review, case report, role 

plays, and live observation. 

Weekly supervision with supervisor. 

Reviews supervisor and CMHW 

notes. Gives suggestions for quizzes 

and role plays to use with CMHW’s 

Guide supervisor in teaching CMHW 

CPT skills.

Effectiveness of Cognitive Processing  Therapy in Kurdistan Iraq

Funded by the Victims of Torture Fund at USAIDPI: Paul Bolton (Iraq), Johns HopkinsConducted in collaboration with Heartland Alliance (Iraq)

A. Situation B. Thought(stuck point)

D. Challenging Thoughts

E. Problematic patterns

F. Alternative Thought

Describe the event, thought or belief leading to the unpleasant emotion(s).

Write thought(s) related to Column A.Rate belief in each thought below from 0-100%(How much do you believe this thought?)

Use Challenging Questions to examine your automatic thoughts from Column B. Is the thought balanced and factual or extreme?

Use the Problematic Thinking Patterns sheet to decide if this is one of your problematic patterns of thinking.

What else can I say instead of Column B?How else can I interpret the event instead of Column B?Rate belief in alternative thought(s) from 0-100%

C. Emotion(s)Specify sad, angry, etc., and rate how strongly you feel each emotion from 0-100%

Evidence?

Habit or Fact?

Interpretations not accurate?

All or none?

Extreme or exaggerated?

Out of context?

Source unreliable?

Low versus high probability?

Based on feelings or facts?

Irrelevant factors?

Jumping to conclusions

Exaggerating or minimizing

Disregarding important aspects

Oversimplifying

Overgeneralizing

Mind reading

Emotional reasoning

G. Re-rate how much you now believe the thought in Column B from 0-100%

H. Emotion(s)Now what do you feel? 0-100%

15

Challenging Beliefs Worksheet

HA BA CPTTX Control TX Control TX Control

Study completers 145 48 66 25 72 22

Non‐completers with post 

assessments

4 0 11 3 10 7

Drop outs/lost to follow up/ 

other non‐completers

9 1 35 5 13 3

Refusals 4 17

Total Intent to Treat 158 49 113 33 96 33

Participation Results

8% 2% 40% 24% 24% 30%Drop out

AlwaysAlways OftenOften SometimesSometimes NeverNever

3 2 1 0

How often the symptom occurs:How often the symptom occurs:

NoneNone a littlea little A A 

moderate moderate 

amountamount

A lotA lot often often 

cannot do.cannot do.

0 1 2 3 4

How much difficulty with each activity?How much difficulty with each activity?

DepressionDepression AnxietyAnxietyTraumaTrauma TraumaticTraumaticGriefGrief

FunctioningFunctioning

DepressionDepression AnxietyAnxietyTraumaTrauma TraumaticTraumaticGriefGrief

FunctioningFunctioning

Effect Size

Difference between intervention 

and controlsCompleters Only  ITT Study

Depression 0.67  0.5 

Trauma Scale 0.84  0.57 

Anxiety 0.79  0.57 

Traumatic Grief 1.05  0.75 

Function 0.87  0.73 

Observations

Getting the CMHW’s through the first case was challenging.

Therapist buy‐in

Initially therapists highly skeptical

Once the therapists completed a case they became generally 

very enthusiastic. 

Appears to have been accepted by the clients. 

Relatively comparable rate of drop‐out with US RCT’s. 

Of the 11 CMHW’s trained in CPT 8 are continuing to provide 

CPT 18 months after the trial has ended.

Low capacity counselors can provide 

specific interventions normally 

requiring experts

Illiterate clients can receive specific 

interventions that previously have 

required literacy

Detailed supervision is more important 

than initial training

Basic approach of CPT unchanged

Kaysen, D.,

Lindgren, K., Sabir

Zangana, G.A., Murray, L., Bass, J., & Bolton, P. (in 

press). Adaptation of Cognitive Processing Therapy for Treatment

of Torture 

Victims: Experience in Kurdistan, Iraq.  Psychological Trauma: Theory, Research, 

Practice and Policy.