Paper short abstract:

A case study of a randomized controlled trial of community-based sociotherapy for Congolese refugees in Rwanda and Uganda

Paper long abstract:

Global mental health as a field of global health has gained increasing recognition due to randomized controlled trial (RCT) based positive evaluations of the effectiveness of innovative delivery systems of packages of care for mental disorders in low- and medium-resource settings. These settings and the context-adapted care packages confront researchers conducting RCTs with critical methodological and ethical issues. Psychosocial support interventions, in particular when targeting people affected by mass violence, raise the complexity of these issues. Rigorous trials to evaluate these interventions are still scarce. Internationally the urgency of more Mental Health and Psychosocial Support (MHPPS) - preferably linked with peacebuilding and implementing a community self-help approach - for war-affected populations is growing. Proven effectiveness of the different kinds of MHPPS interventions as developed over the past decades may lead to more support by governments, international organizations and the non-governmental humanitarian sector for the scaling up of these interventions. Internationally there is a strong faith in RCTs as the tool per excellence to provide the evidence of effectiveness.

This paper focuses on challenges encountered in a still ongoing RCT of the effectiveness of community-based sociotherapy (CBS) for Congolese refugees living in refugee camps in neighboring countries. The major challenge addressed is the tension between the implementation of rigorous research procedures and protocols developed in the West and the implementation of CBS as developed over the past 15 years in Rwanda. In the CBS adaptation to the RCT-linked procedures and protocols what are considered as some of the key characteristics of CBS are crumbling away. On the other hand, there is also some merit in being asked by 'outsiders' to clearly explain the ins and outs of sociotherapy in writing and provide additional documents required for a smooth running of the RCT.

CBS was introduced in Rwanda from Netherlands in 2005. As a Western approach implemented in clinical settings, it was co-creatively redesigned to fit a society shattered by genocide and continuously adapted to changing local contexts, resulting over time in what can be considered a home-grown approach. Once the implementation of CBS in refugee camps has been tested and results are positive, a scale-up of CBS for refugees elsewhere in the world lies ahead. At issue is whether the RCT measured intervention is suitable for such scale-up. This raises the question whether measurement methodologies can be developed that leave interventions to be evaluated intact and are internationally recognized as valid.