Publication: Review of posttraumatic cultural concepts of distress

Although not every human culture would recognize psychological terms as we use them in North America and Europe, every culture has ways of talking about how individuals feel, and every culture has terms that describe extreme and abnormal versions of these feelings. Cultural concepts of distress are those culturally-specific ways that people from within a given group express their psychological distress. For example, Cambodians talk about a khyal attack” as an experience whereby “wind” that flows naturally through the body (akin to chi in Chinese medicine) is blocked from exiting, causing problems that Western psychologists would call symptoms of panic attack (if you’re at all curious, you really should visit the website dedicated to explaining khyal attack).

A couple of colleagues and I recently published a review in Social Science and Medicine of the symptoms that are included in the various ways that different cultures think about the emotional distress following trauma. Our review included 55 studies and identified 116 different cultural concepts of distress. We categorized these concepts based on their symptoms (using hierarchical cluster analysis), and found that the 116 concepts could be described in four basic categories: (1) somatic dysphoria, which largely concerned bodily complaints; (2) behavioral disturbances, “odd” behavior (relative to cultural norms), (3) anxious dysphoria, which as its name implies included lots of anxiety; and (4) depression, which was surprisingly similar to depression as it appears in North American and European medicine. Notably, none of these groups of concepts looked like the psychological disorder that most mental health professionals in North America and Europe think of when they think about trauma — posttraumatic stress disorder, or PTSD.

Of course there are all sorts of limitations to our review, and some would argue that the way we categorized cultural concepts of distress using symptoms alone misses the point of the diversity of these concepts globally (which is broader concerning explanations for distress than it is concerning symptoms). Others would argue that PTSD is actually somewhere in the mix of concepts we reviewed. I’d like to think our review is a starting point for discussion of these issues, rather than a definitive answer to any of these questions.

You can find a link to the publication in Social Science and Medicine here.

One million Syrians in Lebanon: A portrait of daily stressors

The one millionth Syrian refugee in Lebanon was registered recently, and the United States’ National Public Radio commemorated the moment with a illuminating profile of life for Syrian refugees in Lebanon. Reporting from Beirut, NPR’s Alice Fordham reports that Syrians are struggling with multiple daily stressors — those stress-inducing events and conditions of varying degrees of severity that result in large negative effects on mental health.

Notably, of this four-minute radio piece it is not until the second half that Ms Fordham refers to trauma as a problem. Of course, for many Syrian refugees trauma and the emotional consequences of trauma are without a doubt a problem — but they are not the only problem. For psychologists and other mental health professionals the (mostly academic) debate surrounding the roll of common stressful events and conditions is still an unsettled question. For displaced persons, there is no debate at all.

In the interest of disclosure, I come to this debate not exactly as a neutral party: Ken Miller and I proposed a model for integrating daily stressors into conflict and post-conflict research a few years ago. For an alternative viewpoint, see the debate that followed.

Cognitive processing therapy for rape survivors in the Democratic Republic of Congo: Setting a new standard for post-conflict psychosocial care

Last week saw the publication of an important randomized control trial of cognitive processing therapy (CPT) for Congolese survivors of sexual assault in the New England Journal of Medicine (NEJM — and thanks, NEJM, for making the article available in full online). The fruit of intensive work by Judy Bass of Johns Hopkins, Jeannie Annan of the International Rescue Committee, Debra Kaysen of the University of Washington, and a host of others, this publication sets a new standard in the field of post-conflict mental health research and is welcome news for those affected by rape and other forms of sexual assault in low and middle-income (or, “LMIC”) war-affected settings.

The study involved almost 500 female survivors of rape in the eastern provinces of the Democratic Republic of Congo (DRC), an area of the world infamous for the absence of state control and an ongoing epidemic of sexual violence. Half were randomly assigned to a group-based version of CPT led by trained local counselors, half to generalized, patient-directed individual support and case management. Those attending CPT improved far more than those in the control group (although the latter also improved somewhat).

CPT has been shown to be effective for sexual assault survivors in several Northern, high-income countries, so that it was effective in the DRC may seem unsurprising. However, debates have raged in the past decade or so about the efficacy and effectiveness of doing psychotherapy in post-conflict settings that are not technically “post”-conflict and in populations with low-levels of education.

Prior research has suggested that short-term therapies may not be effective for populations exposed to ongoing trauma or multiple severe traumas. In our study, all villages reported at least one major security incident during the trial, including attacks, displacement due to fighting, and robbery by armed groups. In addition, there was concern that providing therapy to illiterate persons would be challenging. Our findings suggest that despite illiteracy and ongoing conflict, this evidence-based treatment can be appropriately implemented and effective.

This study shows that, with sufficient technical support, psychotherapy targeting trauma-related emotional problems can be delivered effectively in violence-affected LMICs as part of comprehensive psychosocial programs.

For a brief summary of the study and some commentary, see the related New York Times article from last Wednesday.

WEIRD paper redux

Ethan Watters is at it again. Watters is the author of Crazy Like Us the book and blog of the same name, and a few weeks ago he published “We Aren’t the World” in Pacific Standard, a very readable piece about the WEIRD paper — Heine, Norenzayan, and Henrich’s “The Weirdest People in the World.” The paper is not new — it was published in 2010 — but it does continue to raise intriguing questions about the cultural specificity of most findings in psychology.

What’s WEIRD? Western, Educated, Industrialized, Rich and Democratic. What’s weird about them? It turns out they… er, we… are probably the worst population to do psychological research with if you want to get a picture of the average human psychology. Read the paper here.

Refugees, 2013: Changing faces, changing places, changing policies

This week’s Economist has a fine summary of how refugees have grown in number and diversity, and the international community’s response to these changes. Among things to note is the continuing trend observed a few years ago in a JAMA commentary (and critiqued by a skeptic or two… oops) of urban resettlement, which UNHCR now says it prefers to people resettling in refugee camps. UNHCR is also more explicit about its policy encouraging local political integration and even economic development as solutions in long-term refugee crises. These efforts are mirrored by changes in policies of countries who receive the most refugees (overwhelmingly in the developing world).

David Apollo Kazungu, Uganda’s Commissioner for Refugees, says it no longer makes sense to treat refugees as a humanitarian issue. “Those who stay for years throw up developmental problems for us, such as how to find enough land, water and jobs for everyone,” he argues. Uganda has already tried to improve the lot for the nearly 200,000 refugees it hosts by placing them in settlements rather than camps, and by giving them land to farm.

Within this discussion is the acknowledgement that forced migration and voluntary (or economic) migration are not entirely separate phenomena. Read the entire article here.

Sandy IDPs & some good mental health information for New York & New Jersey

If you have paid attention to any news from the Northeast U.S. in last couple weeks, you know that here in New York and across the river in New Jersey many people are hurting in the wake of the “superstorm” Sandy. According to the New York Times, there are an estimated 10,000-40,000 internally displaced persons (IDPs) in New York City alone. In response to the massive loss and devastation along the waterfront, there have been many heartwarming displays of care by neighbors, friends, and even complete strangers. And in contrast to the response to Hurricane Katrina in New Orleans, local government and even the Feds seem to have their act together in providing supplies and now housing to those displaced.

IDP issues may, however, become a long-term issue. The sudden loss of material goods and social connections that people have based on where and how they live can have long-term consequences for social capital, employment opportunities, and even just knowing how to complete everyday tasks (e.g., where to get healthy food for your kids). The outpouring of support needs to be transformed into long-term engagement with IDPs, along the lines of the better psychosocial programs undertaken in more severe IDP crises (e.g., in Medellín, Colombia).

In the meantime, there has been a little attention to mental health. The best I have seen so far has been a post by “The 2×2 Project,” a blog written by Dr. Lloyd Sederer out of Columbia University’s Mailman School of Public Health. (A thank you to my wife, who forwarded me the link.) Here’s the intro, which sums up and corrects the myths that are often hears in immediate post-disaster environments:

In the aftermath of Hurricane Sandy, opinions—some reliable, some misleading— about the storm’s potential mental health impact have proliferated. When media channels act responsibly they engage experienced experts as spokespeople; when that does not happen, wrong information adds to the public’s anxiety and can foster inappropriate clinical interventions and waste resources.

In the latter category, perhaps the greatest myths I have heard are:

Post-traumatic stress disorder (PTSD) can appear in the immediate wake of a disaster.

Watching television can cause PTSD.

The highly common psychic distress in the wake of a disaster is a mental illness.

Here are some facts:

Psychic distress after a disaster, which can be highly prevalent and last up to a month, generally is a normal reaction to an abnormal situation.

Read the rest of the post (and check out other informative posts) here.

Global Mental Health Capacity Building at the 2012 ISTSS Annual Meeting

The annual meeting of the International Society for Traumatic Stress Studies (ISTSS), this year held in Los Angeles, wrapped up this weekend. This year’s theme, Beyond Boundaries: Innovations to Expand Services and Tailor Traumatic Stress Treatments, was in large part a response to a lack of global and cross-cultural perspectives at most ISTSS meetings. This year the planning was directed by two global mental health researchers, Debra Kaysen (University of Washington’s Global Mental Health program)and Wieste Tol (Johns Hopkins). Thanks to Debra and Wietse and their deputies (disclosure: the latter crowd includes yours truly), global perspectives were given the main stage. This was most obvious in two of the keynote addresses, one by global mental health luminary Vikram Patel (Kings College London School of Hygiene and Tropical Medicine and founder of Sangath) and longtime transcultural psychosocialist Joop de Jong (the founder of Transcultural Psychosocial Organization (TPO), professor at VU Amsterdam (which is the link), the University of Amsterdam, Boston University, Rhodes University in South Africa). (A request to academics from the blogosphere: If you’re going to hold appointments at multiple institutions, please host your own website — finding which link to post ain’t easy.)

In addition to the international perspectives, it was good to hear the issue of capacity building addressed head on. This was addressed in the keynotes, but it also had it’s own symposium. Theresa Betancourt (Harvard) chaired “Capacity Building in Low-Resource Settings,” and she laid out the issue as movement from “relief to resource,” which sums it up nicely. Speakers included Vikram Patel, Mary Fabri (formerly of Heartland Alliance in Chicago), and Joop de Jong. One of the key problems in global trauma practice is that mental health professionals from high income countries fly in to low and middle income countries (LMICs), do their thing for a few weeks or a few months, then fly out — leaving nothing in terms of increased ability to deal with the long-term issues related to disasters, let alone in terms of preparation for subsequent ones. Capacity Building in Low-Resource Settings was a discussion of how to guard against this all too frequent phenomenon.

Vikram Patel noted that a key to “scaling up” access to empirically supported treatments was identifying “primary tools of mental health… skilled human beings.” Patel is well-known for advocating “task-shifting” to “nonspecialists” — in the US we would call them paraprofessionals. His preferred term is “counselors,” as it is a now globally familiar term because of the widespread use of counselors for medication adherence issues in HIV/AIDS work and breastfeeding (the two global public health predecessors Patel looks to as models for global mental health). Important “soft skills” (i.e., non-content specific capabilities) that are basic to counseling include: engaging patients, assessing their mental health, suicide assessment, and knowing when to refer to more skilled professionals. The next stage of training involves advanced competencies that are disorder-specific, treatment-specific, and health context specific. Acquiring these competencies involves brief (a few days) classroom training and then moving trainees on to supervised field work (a few months). One of the major stumbling blocks to sustainability of any counseling program is the lack of consistent supervision. Patel has moved to a model that includes peer supervision with web-based (e.g., Skype) supervision done remotely. He noted that as very often counsellors do much more therapy than senior supervisors, peer supervision is often better than supervision by senior intervention researchers.

These themes were taken up by Mary Fabri and Theresa Betancourt in explications of their clinical interventions efforts with women in Rwanda and former child soldiers in Sierra Leone, respectively. A common problem was remote supervision. Certainly Skype and other web-based communication helps connect experienced clinicians, but connection speeds being what they are — or rather, what they are not — in many lower income countries, these are often simply not feasible. Fabri makes frequent trips, and Betancourt gets by with large telephone bills for weekly supervision.

Only just touched upon was how these programs, sustained largely with external funding, can be integrated into a countries’ national health strategies. One particularly sticky issue related to certification. Joop de Jong noted that “professionalizing” lay workers has historically been accompanied by nongovernmental organizations’ (NGOs) ignorance to local politics. The inability to engage established local authorities makes them (understandably) angry, which then leads to barriers to certifying those who have been working with NGOs following post-conflict periods (and may extend to them being unable to access educational resources as well). It is during these “post-post-conflict” periods where the sustainability of programs is proven.

Left untouched was the issue of building research capacity. But research capacity building was not left undiscussed at the conference. Later in the evening I had the good fortune to be at dinner with Marc Jordans, the Research Director at HealthNet TPO (also at Kings College London School of Hygiene and Tropical Medicine), who has made research capacity a priority. He explained the process as excruciatingly slow, as the challenges are largely educational. Here’s where the distinction between lower income countries and middle income countries is critical. Middle income countries (MICs — e.g., India, Peru) tend to have university systems, and therefore a pool of educated researchers in a field that uses research methods applicable to mental health research (.e.g, sociology, anthropology, public health); lower income countries (LICs — Sierra Leone, Nepal), however, often have one or two universities, and a very small pool of people with the base level research understanding to build upon. In essence, groups like HealthNet TPO are engaged in educational development, which, like all development work, is a multi-decade proposition. Jordans added, however, that the payoff for homegrown LIC researchers with a PhD is great, given that they are one of a few in their countries with the expertise and legitimacy to advise governmental and international organizations working in their regions.


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