Torture

Transdiagnostic mental health interventions capitalize on commonalities and similar components across EBTs (e.g., psychoeducation, cognitive processing) (e.g., [19] (link)). Transdiagnostic approaches involve teaching providers a set of these cross-cutting treatment components, with decision rules and guidelines for which components to use for which presenting problems. Component selection, sequencing, and dosage (e.g., number of sessions per component, number of sessions for the treatment) can be varied based on individual symptom presentation, comorbidity, and most disturbing current problem (e.g., avoidance of trauma triggers or intrusive trauma-related memories). Detailed guidance in these areas is particularly important in low-resource settings when using a task-shifting approach, as providers do not a have mental health background. In HICs, individuals with mental health training may be better able to “flex” manualized EBTs to address individual client needs (e.g., adding a component, extending treatment duration or dosage for a particular component), given their training and experience. In HICs, transdiagnostic approaches have been proposed to address concerns about scale-up of EBTs such as the time and resources needed for training a workforce in multiple EBTs and achieving mastery and fidelity across multiple EBTs [20] (link),[21] (link). Initial studies of such approaches in HICs have demonstrated effectiveness and a positive response from providers [22] (link)–[24] (link).
CETA is a transdiagnostic treatment approach developed by two authors (L. M. and S. D.) for delivery by lay counselors in low-resource settings with few mental health professionals [9] . Like transdiagnostic approaches developed for HICs, CETA was designed to treat symptoms of common mental health disorders including depression, PTS, and anxiety. Differences between CETA and HIC-based models include the following: (1) fewer elements, (2) simplified language, (3) brief step-by-step guides for each element (1–2 pages), including example quotes of what counselors could say, (4) specific attempts to make the complex concepts of cognitive coping and cognitive restructuring components more accessible to counselors and clients, such as the use of concrete strategies often used in child-focused interventions, and (5) training the provider in element selection, sequencing, and dosing for each client rather than having decision-making done by higher level professionals (who may not be widely available in low-resource settings). For this population, CETA was used to treat depression, anxiety, PTS, aggression, stress due to current life problems, and alcohol abuse, problems that emerged as priorities during a prior qualitative study [25] among individuals similar to those included in this study. CETA as used in this study consisted of nine elements that focused on a torture- and violence-exposed population. These elements are listed and described in Table 1. They include an element to address alcohol abuse: screening and brief intervention (SBI) for alcohol [26] (link). The SBI element was developed based on motivational interviewing techniques [27] to provide feedback on a personalized assessment of drinking and to assist the client with identifying steps he/she might want to take to reduce or stop drinking. Counselors delivered CETA during weekly 1-h sessions with the client, practicing skills both in and between sessions.
To facilitate acceptance of these skills, counselors tailored the CETA CBT skills to the individual and familial needs of their clients, as well as to the cultural needs of the Burmese community, by using Burmese folktales, personal anecdotes, and local expressions or adages to convey key principles. Cultural modifications also included building on existing strengths (e.g., support of family and community) and existing coping strategies (e.g., meditation, singing songs, having tea with friends) to increase daily functioning. Clients also were encouraged to invite family members and close friends to introductory sessions in order for others to understand the role of counseling and to support the client in the treatment. Clients received CETA in familiar venues where the client felt most comfortable, including the home of the client or counselor, local Burmese-run clinics or community organizations, and secluded outside areas.
Counselors and supervisors were trained using the apprenticeship model [28] (link). This included a 10-d in-person training followed by practice groups. Practice groups were led by one of three local supervisors, with 3–6 counselors per group practicing CETA elements with each other, supervised by the local supervisor. Following the practice groups, each trainee then treated one pilot client under close supervision by the local supervisors, prior to treating participants in the RCT. Throughout, local supervisors received at least 2 h per week of supervision from the US-based CETA trainers (doctoral-level psychologists) by phone call, Internet call, and/or email. At each stage, the apprenticeship model included feedback loops encouraging local counselors and supervisors to modify delivery of components to increase the fit with the culture and local setting, based on their ongoing experiences. For example, counselors and supervisors could suggest using different ways of stating ideas, or change analogies and examples to improve understanding. Only after successful completion of a pilot case did counselors begin to treat participants in the RCT. If counselors encountered problems such as an inability to complete practice role plays and/or frequently having to repeat elements with the first pilot client because of mistakes, then they took on a second pilot case under close supervision. CETA trainers and local supervisors discussed counselor performance and jointly made decisions about the need for an additional pilot case during weekly Internet calls.
Supervision groups continued throughout the RCT, with each local supervisor meeting with a small group of counselors for 2–4 h per week. Local supervision involved presentation of each and every case, review of client assessments and counselors' treatment plans, review sessions (fidelity monitoring), role plays to practice components, and planning upcoming sessions. All cases were then reported on and discussed with US-based CETA trainers each week, who documented details of each case. Fidelity tracking was done through a multi-tier review approach. Specifically, counselors tracked their own fidelity by following their step sheets and checking off each step on their own step sheets. They also completed a monitoring form for each session, which included documentation of the component delivered and some steps for each component. Supervisors reviewed fidelity during the supervision groups by reviewing the monitoring forms and requiring in-person objective reporting (e.g., “I started with step one, and said we would be working on relaxation exercises because sometimes the client needs skills to reduce stress. Then I taught breathing, describing what we would do, showing the client an example, and had the client practice.”), rather than subjective reporting (e.g., “The client seemed mad and didn't want to work.”), during supervision. This allowed the supervisor to determine which steps within the component were delivered and whether they were delivered correctly. The final and third layer of fidelity checking was completed during weekly Internet calls between supervisors and US-based CETA trainers. Supervisors provided an objective report of the sessions for each case, and the trainers asked questions specific to the steps and the way in which they were completed. If errors within a session occurred (e.g., failure to complete a step, step delivered incorrectly), the supervisor coached the counselor to redo this component or step during the following session.

The HTQ is a five-section self-report questionnaire. The first part lists a series of traumatic events (41) to which the individual subject will answer yes or no. In the second section, comprising of two open-ended questions, the subject is asked to describe in more detail the event that he found the most traumatizing, whether in his country of origin or since in exile. The third part assesses the risk of neurological complications that may result from certain traumatic events. The fourth part consists of 40 items assessing the psychological impact. The participant is asked to rate each item on a four-point Likert scale (1=not at all, 2=a little, 3=quite a bit, and 4=extremely). The first 16 items such as “recurrent thoughts or memories of the most hurtful or terrifying events” or “feeling as though the event is happening again” attempt to assess the accepted symptoms of PTSD diagnosis (Part 4 – PTSD). The following 24 items, named by the authors “refugee-specific”, lean more toward the impact that the traumatic experiences may have had on the subject's perception of his/her daily lives (Part 4 – Functioning). The fifth and final section offers a list of 29 acts that are considered to be torture.
The validation study of the original version was conducted among 91 patients originally from Cambodia, Laos, and Vietnam, receiving treatment at the Indochinese Psychiatric Clinic. Reliability and validity were determined by comparing the results of the questionnaire to the clinician's DSM III-R diagnosis elaborated with a semi-structured interview. The results of this study show that the internal consistency for Part I (0.90) and for Part IV (0.96) was robust. Total item-score correlation coefficients were 0.56 for Part I and 0.65 for Part IV. Furthermore, the criterion validity study showed, for a threshold of 2.5, a sensitivity of 0.78 and a specificity of 0.65 (Mollica et al., 1992 (link); Mollica et al., 1996 ).

The event list of the PDS assesses the exposure to 12 traumatic experiences across the life span that involve a serious injury, a life threat, or sexual assault to the individual themselves or witnessing such an event⁴¹ . The following events were evaluated: serious car accident, natural disaster, violence by a member of family or other relatives, violence by a stranger, sexual violence by a member of the family or relatives, sexual violence by a stranger, combat or exposure to a war zone, other unpleasant sexual experiences, captivity, torture, life-threatening illness, and other experiences (e.g., witnessed traumatic experiences). Each traumatic experience was checked if it had been experienced at least one time during life. The overall trauma load was calculated as the sum of different traumatic event types, potentially ranging between 0 = no exposure at all and 12 = exposure to all types of traumatic events.
Current symptoms of depression and anxiety were measured with the Hopkins Symptom Checklist-25 (HSCL-25)^{42 (link)}. This instrument has 15 items for depressive symptoms and 10 items for anxious symptoms. All items were rated for the last week on a scale ranging from 0 = not at all true, 1 = a little, 2 = quite a bit, and 3 = extremely. For both, symptoms of depression and symptoms of anxiety, we calculated the mean of the 10 and 15 items. The HSCL-25 showed sufficient internal consistency, Cronbach’s α = 0.78 in the Greek Sample, Cronbach’s α = 0.89 in the Spanish Sample, Cronbach’s α = 0.92 in the Peruvian Sample. We applied the cut-off > 0.75 for the mean scores of symptoms of depression and anxiety of the HSCL-25 to describe the percentage of clinical relevant symptoms^{43 (link)}.