标题：The Effect of Cognitive Therapy on Structural Social Capital: Results From a Randomized Controlled Trial Among Sexual Violence Survivors in the Democratic Republic of the Congo
摘要：Objectives. We evaluated changes in social capital following group-based cognitive processing therapy (CPT) for female survivors of sexual violence. Methods. We compared CPT with individual support in a cluster-randomized trial in villages in South Kivu province, Democratic Republic of the Congo. Local psychosocial assistants delivered the interventions from April through July 2011. We evaluated differences between CPT and individual support conditions for structural social capital (i.e., time spent with nonkin social network, group membership and participation, and the size of financial and instrumental support networks) and emotional support seeking. We analyzed intervention effects with longitudinal random effects models. Results. We obtained small to medium effect size differences for 2 study outcomes. Women in the CPT villages increased group membership and participation at 6-month follow-up and emotional support seeking after the intervention compared with women in the individual support villages. Conclusions. Results support the efficacy of group CPT to increase dimensions of social capital among survivors of sexual violence in a low-income conflict-affected context. Women who experience sexual violence have an increased risk of mental health problems, 1 including posttraumatic stress disorder (PTSD), depression, anxiety, and social maladjustment. 2 In the Democratic Republic of the Congo (DRC), studies show that upward of 40% of women experience sexual violence. 3 Many of these women are rejected by their husbands and family, experience poor standing within their communities, 4,5 and suffer what Kleinman 6 refers to as social death— exclusion from social and community life. This community reaction is in part a product of existing dynamics of gender inequality and harmful gender attitudes that blame sexual violence survivors. 7 In community contexts where interpersonal trauma rates are high, healing needs to involve social factors in addition to addressing psychological effects of these traumas. Studies show that losses to social resources occur following rape, 8 but the literature has yet to focus on whether these resources can be restored or improved. Within low-resource settings that lack adequate health infrastructure, people may rely on less-formal community social ties to meet their mental health needs. Within this context, the effects of sexual violence on the relationship between mental health and social resources can be partially explained by utilizing a social causation or social drift framework. 9 Social causation suggests that losses to social resources are associated with increased mental health problems. In DRC, negative reactions of others close to the survivor in response to sexual violence can affect women’s ability to function socially within their communities; this in turn could exacerbate or lead to mental health problems. 10 Social drift involves mental health problems leading to decreased social resources. High levels of distress after sexual violence can lead to social withdrawal because of feelings of distrust, shame, and loss of self-esteem inhibiting social functioning. This framework suggests that reducing mental health problems would lead to increases in social resources and that increasing these resources would lead to reductions in mental health problems. Social capital is a multidimensional concept that is useful when one is investigating attributes of the social environment that may positively contribute to mental health. Grounded in sociology, social capital was defined as resources available to an individual through group membership and social networks 11 and through norms of reciprocity. 12 Following these earlier definitions, social capital is formally delineated into cognitive (e.g., perceptions of trust) and structural (e.g., group membership) domains 13,14 and whether the concept is measured at the level of the individual (as is the case in our study), or as an aggregated community asset. 15 Individuals endowed with greater social capital have better health 16 and mental health outcomes. 17 In a systematic review, greater structural social capital was protective against common mental disorders. 18 Taking an individual-level perspective, 19 people with greater structural social capital would have greater access to social support. Greater social support is implicated in recovery from sexual violence 20 and, across contexts, lacking this support is the most robust predictor of PTSD. 21,22 Increasing access to social support by broadening structural social capital within communities suffering from widespread trauma could provide critical recovery resources and enhance the posttreatment recovery environment. Therefore, interventions need to be evaluated with regard to their ability to enhance structural social capital and social resource engagement in low-resource settings. To our knowledge, no previous studies have examined whether an evidence-based psychotherapy implemented to improve sexual violence–related distress increases structural social capital in a low-resource, conflict-affected context. We obtained data for this study from a randomized controlled trial of a group version of cognitive processing therapy (CPT) for female survivors of sexual violence conducted in DRC, which demonstrated efficacy for the treatment of mental health problems. 23 Cognitive processing therapy targets unhelpful beliefs and avoidance behavior 24–26 that could lead to or maintain losses in social resources. Many survivors of sexual assault report unhelpful beliefs about trust, the dangerousness of individuals and the world, power, esteem, safety, and intimacy. 27–29 Survivors commonly avoid people, places, and situations that remind them of their trauma. 30–32 Decreasing negative beliefs and avoidance could increase structural social capital, as survivors may be more able and willing to seek relationships. 33,34 Apart from the possible treatment effect based on CPT techniques, we would expect that a group treatment format may increase structural social capital by supplementing social capital lost following rape. 35 We hypothesized that, on average, women in the CPT condition would demonstrate greater increases in structural social capital compared with women in an individual support (IS) condition. We further expected that women in the CPT condition would engage in greater emotional support seeking than women in the IS condition.
