Though veterinarians have long diagnosed behavioral problems in animals, the concept of canine PTSD is only about 18 months old, having come into vogue among military veterinarians who have been seeing patterns of troubling behavior among dogs exposed to explosions, gunfire and other combat-related violence in Iraq and Afghanistan.

Here’s how my canine-concerned colleagues conceptualize the disorder:

In each case, Dr. Burghardt theorizes, the dogs were using an object, vehicle or person as a “cue” for some violence they had witnessed. “If you want to put doggy thoughts into their heads,” he said, “the dog is thinking: when I see this kind of individual, things go boom, and I’m distressed.”

See? PTSD. Or maybe just good doggy thinking. Or maybe we’ve seen this before in animals and we want to give it some label that means more to us than what happens when the early behaviorists shocked rats to demonstrate conditioning. Stimulus – response. Cue – stimulus – response. Cue – response.

This is a perfect example of how previously recognized behavioral phenomena are relabeled by popular authorities as psychopathology based on recent cultural historical events. For a quick read on this phenomenon, see Ethan Waters’ Crazy Like Us. Read the New York Times piece on Canine PTSD here.

What may be the best thing about the HESPER guide is the presentation. Van Ommeren and company have provided not only the measure and the methods used for development of the measure, but also sections on training local administrators, appropriate sampling, a mock interview transcript that reads true, and even a section on how to present HESPER findings to organizations. Too often I have seen an disaster relief NGO get a measure that may be valid or may not, administer it haphazardly, and then be unsure of how to meaningfully present findings. In addition, there’s an “Other things to consider” section which includes the things that you don’t usually think about but are blatantly obvious on the ground — the dilemma of raised expectations that often come about just by asking about problems, for instance.

And then there’s this:

1.2 WHO MAY USE THE HESPER SCALE?

The HESPER Scale may be used by anybody in its current form for non-commercial purposes. Should you wish to make any modifications to the scale, or translate the scale into another language, you will need to get permission from WHO Press (for contact details, see inside cover page). Currently the HESPER Scale (i.e. Appendix 1 only) is available in English, French, Spanish, Arabic, Nepali, and French / Haitian Creole. Word files of the different HESPER Scale language versions are available upon request.

The WHO provides their measures for free and welcomes further development of these types of rapid assessments.

The article, Posttraumatic idioms of distress among Darfur refugees: Hozun and Majnun, details the development of a questionnaire (a structured interview, really) for Darfur refugees that we used to help evaluate a psychosocial intervention in camps in Chad. From the article:

We took an emic-etic integrated approach, identifying local constructs and then measuring both Western and local distress constructs within the same population in order to compare associations between two sets of symptoms of theoretically related concepts.

This means we (1) talked to a lot of refugees to hear how they defined their problems (including symptoms of psychological distress) and then followed-up with traditional healers to hear how they categorized these symptoms into larger psychological problems (“idioms of distress” for you budding transcultural psychiatrists out there); and (2) conducted a survey that included these problems and Western concepts (PTSD, depression) to measure how the Darfur problems and Western concepts were differentially associated with trauma experiences, loss, and impairment in daily living. The two Darfur problem sets were labeled hozun — “deep sadness” — and majnun — “madness.”

I’ll let you read the article to get the details, but suffice it to say that these sets of disorders — hozun and majnun on the one hand and PTSD and depression on the other — shared many symptoms in common. Related to this, they were associated with traumatic events and functional impairment at comparable levels — in other words, one could “predict” functional impairment using hozun and PTSD and get similar effect sizes (with slight favor for the locally-defined problems).

One might think that if a measure of PTSD is as good as measure developed for a local distress idiom in predicting a third variable you are interested in, then there is really no reason to develop the local measure. In the article we emphasized that the response to this argument had to do with respecting local populations and avoiding psychiatric colonialism. Now although I agree with those ideals, I would emphasize another point we made (but did not emphasize): Just because many of the symptoms of two different disorders from the Western psychiatric canon (here PTSD and depression) overlap with two different disorders from a different medical tradition (here hozun and majnun), it is how the symptoms are arranged in their respective traditions that define the disorders. From the article:

although they accounted for similar variance in Study 2 as a set of items, these symptoms were categorized by traditional healers into sets that were different that the sets of symptoms in PTSD and depression. This, then, suggests that it would be incorrect to argue that PTSD and depression are culturally valid constructs in settings in which respondents report variance on PTSD and depression simply because of that variance.

In other words, just because non-Western participants in a study answer that they have problems (or do not have problems) that fit into Western DSM-IV ideas of psychiatric disorder does not mean that Western DSM-IV ideas of psychiatric disorders are valid definitions of their problems. Figuring out what are valid definitions for their problems is not, at its most basic, a statistical task, but rather a theoretical one. You have to talk to the people who know the theory, not just the people who have the problems.

The numbers and the asylum process

The Times piece cites a figure that immigration courts in the U.S. granted (approved) 51% of cases as evidence of the system’s credulity. Setting aside assumptions about what the “true fraud percentage” should be for the moment, this figure makes sense if you think the asylum system is a single process. However, ever since the 1996 Immigration Reform Act, when asylum was tightened in order to prevent fraud, getting asylum has been a two-tiered process, one called Affirmative asylum, and one called Defensive asylum. The Affirmative process is the initial review of applicants’ cases by an Asylum Officer during a single Asylum Interview. Asylum Officers are experts in conditions of the applicant’s country, and are charged with approving cases that are consistent with facts on the ground in applicants’ countries, and to deny cases that lack sufficient evidence or are suspect. Here is the DOJ’s description int he report cited by the Times and New Yorker:

Aliens who file affirmatively with DHS [Department of Homeland Security], but whose requests are not granted, may be placed in removal proceeding and referred to the appropriate immigration court for further review of the case.

In other words, the Affirmative process is designed to identify and approve the easy cases and refer the rest on to Immigration Court (see below). According to the DOJ’s report, the approval rate in the Affirmative system was 61% in 2010, lower in the five years prior.

Defensive applications for asylum are processed in Immigration Court. Immigration Court is the redheaded stepchild of the U.S. justice system, with no stated rules of evidence and dockets that would make a Criminal or Civil Court judge nauseous. Asylum cases in Immigration Court generally proceed over two or three meetings over the course of two years (lately even longer), leaving applicants in legal limbo in the meantime. The Defensive process is designed to be adversarial, with a prosecutor poking holes in the applicants’ cases and applicants – or applicants’ lawyers – defending their cases. According to the DOJ’s report, approval in the Defensive system was 35% in 2010, and it has been at this rate (between 34-37%) since 2006.

The Times article notes that rates of approval are up – but according to DOJ they are only up in the system designed to deal with the easy cases.  Rates have held steady, at just over a third, in the system designed for the cases with insufficient documentation – and, speaking to the interest of the recent media coverage, presumably more likely to be fraudulent. Bottom line: The part of the system most likely to handle fraudulent cases rejects two-thirds of cases, and that proportion has not changed substantially in years.

There’s a larger problem, of course, in stating that any percentage of approvals is evidence of fraud: There’s no way of knowing what the “true fraud percentage” really is. The Times piece admits this, but suggests that the rates in the DOJ report are too high, singling out New York City approval rates of 76% in 2010. The New York rate comes from the division of total completions in New York in 2010 by receipts (Table 6 in the DOJ report), and is, first of all, wrong — completions are not grants, and if you look at the chart you’ll see that the same math in other districts where completions outnumbered receipts would result in rates that are greater than 100% — but is more fundamentally misleading in that it assumes that 24% is an underestimate of a true percentage that just can’t be seen in these numbers. The DOJ report was a simple review of approvals and denials, not an experimental study or even an observational study of asylum fraud. There is no way to justify the description that fraud is “widespread” from the report cited in the article. The New Yorker article is a little bit better in its use of numbers, but Mehta’s portrayal on NPR interview that “most of these stories” asylees tell include “a little bit of untruth” is completely unknowable from the evidence he gathered. He hung around one woman, whose story may or may not be like “most” others. Her story is  compelling but that does not make it representative.

The story the DOJ numbers do support

Now, how about those numbers actually displayed in the DOJ report that the article cites? Consider the following, directly from the DOJ report:

As shown in Figure 14 below, asylum receipts declined by 42 percent and asylum completions declined by 30 percent from FY 2006 to FY 2010.

Here’s Figure 14, below:

It’s a little fuzzy here, but the story is clear: Since 2007, asylum claims (“receipts”) and completed cases (both approvals and denials) have dropped by a little less than half.  Completely ignored by the Times and the New Yorker, fewer and fewer people are claiming asylum, and those that are wait longer to have their cases completed. Why might this be? Has stepped up immigration enforcement resulted in more legitimate cases not getting to the U.S.? Or are the numbers simply a result of the economic downturn? And why the marked difference in receipts and completions  in 2010? Hm, there’s a story.

P.S.

There’s another larger story about asylum’s place in the immigration debate in the DOJ report, though you’d have to contextualize it a bit: In 2010, among completed cases, approved and denied cases together accounted for just under 20,000 cases nationally. For those concerned that asylum provides a “free pass” for undocumented immigrants, consider this: Of an estimated 12 million undocumented immigrants in the U.S., those attempting to get in through asylum in 2010 accounted for approximately 0.17% (that’s 20,000 divided by 12 million), or less than one fifth of one percent.

Dogs bring home war’s stress, too

SAN ANTONIO — Dogs suffer from post-traumatic stress, too.

Years of war and frequent deployments have affected military working dogs just as they have humans, and Dr. Walter Burghardt is trying to do something about it.

Dr. Burghardt explains:

“The dogs that go overseas … we’re starting to see some distress-related issues,” he said. “It results in difficulty doing work. They’re distracted by loud noises. We’re not saying it’s the same as in people, but there are common things.”

That includes hypervigilance or showing interest in escaping or avoiding places in which they used to be comfortable. For example, a dog that used to work at a security checkpoint or gate may try to pull away on his leash when he sees he’s being led to that checkpoint or gate, Burghardt said.

Some of the dogs also become very clingy or more irritable or aggressive, the doctor said.

“Canine PTSD” is either the most extreme example of what Richard McNally calls PTSD’s “bracket creep” or some perhaps nonintentional Pavloivan insight into the nature of stress response. Or perhaps both. If we take the “symptoms” reported in the article as accurate, and I have no reason to doubt the staff writers at the Army Times, then yes, dogs get stressed and want to avoid the sources of their stressors — classical conditioning, a la Ivan Pavlov (1849-1936; Pavlov even demonstrated conditioning using dogs, until they drowned in their cages when the River Neva flooded the basement of his laboratory). But canine posttraumatic stress disorder?

In case you were concerned that the Army veterinarians were not being careful about differential diagnosis, or perhaps even that some dogs might be faking in order to cash in on the generous disability benefits for veterans with PTSD:

[Dr. Burghardt] cautioned, “canine [post-traumatic stress disorder] is only diagnosed if the dog has combat exposure or repeated, prolonged deployments.”

The article continues with a description of the treatment given the dogs to get them right back “in the service”… which is, of course, the goal of treating human PTSD in the military as well.

One of the most striking films shown (so far) comes from Robert Lemelson’s psychiatric anthropology series, Afflictions: Culture and Mental Illness in Indonesia. In “Shadows and Illuminations,” a man presents with visual and auditory hallucinations of Balinese spirits, disorganized behavior and inappropriate dress. His family and neighbors regard him as odd, so it’s not the case that he is just odd to our foreign eyes. Our psychiatric practice tells us to look for schizophrenia. He reports the symptoms began with the death of his daughter, and we think perhaps it is a posttraumatic stress reaction of some sort. He is examined by two traditional healers and a psychiatrist, all of which have their own treatments, but none of which seem to help. Accommodations are made for the man’s behavior in his own home, and he seems to get a little better. Improvement had nothing to do with our diagnosis, or lack thereof.

Each story in the series situates behavior and concepts of illness within the families and societies in which they occur. Not satisfied with biological explanations of these patients’ problems, Lemelson’s films remind us that psychiatric practices have non-psychiatric implications, specifically around family relations, historical meaning-making, and even implications related to the freedom of the individuals with mental health problems.

Why do psychologists care about this? Many of us use responses to questionnaires as our representation of people’s emotions, and if a certain group of people are responding on the low end of the scale and another group on the high end and we want to compare them, we need to know the characteristics of each group’s response style in order to tell if they are in fact having different reactions or not. And now I have a study to help me explain Grandma’s response style.

First, credit where credit is due: it was Andrew Ryder of Concordia University that passed this study along, in a class on statistical models in emotion research. The class is part of McGill University’s Summer Program in Social and Cultural Psychiatry, which I am attending through the month of May. (In my humble opinion McGill has the best collection of thinkers on how culture shapes emotions, cognitions, and perhaps most importantly the practice of mental health.) Professor Ryder was discussing his own work on differences in behavior between depressed European-origin Canadians and depressed Chinese, and noted that each group had particular norms for emotional expression of happiness — for example, when to smile, what to smile at, even how to smile. Note here that emotion researchers make a distinction between emotions — the actual feelings — and emotion behaviors — the things you do to show the feelings.

When emotion researchers talk about happiness behavior, they almost always mention that U.S. Americans are really into expressing their happiness, as did Prof. Ryder. But, he added, there is significant variability in the expression of happiness in U.S. that is connected to cultural identity, even cultural identity four- or five-generations removed. And this brings us to Scandanavian Americans — those U.S. residents with ancestors from Sweden, Denmark, Norway and Finland. It turns out that they are different.

In Variation among European Americans in emotional facial expression, Jeanne Tsai and Yulia Chenstova-Dutton compared facial expressions among “Scandinavian Americans” and “Irish Americans” after inducing six emotions (happiness, pride, love, anger, disgust, and sadness) through a somewhat convoluted (if ethical) “relived emotion task.” And what did they find? What any Swedish grandmother will tell you: the Irish are more emotional. Or, to look at the other side, as Prof. Ryder did, “You have to control for Scandinavian Americans’ ‘Scandinavianness’ to get them to look like the rest of Americans.”

I don’t want to get too emotional here, but I kind of think my Scandinavianness is not too bad — although I don’t want to make a big deal about it.

In a chapter titled “Windshield Ethnographers,” Hodge introduces us to the Human Terrain System which was based on the idea that “brigade commanders needed social scientists to provide advice” so that they didn’t have to rely on a “library loaded with ethnographic data” when making their rounds establishing alliances with local sheiks and mullahs. Five-person Human Terrain Teams would be embedded with brigades or regiments in order to provide intelligence — or, as social scientists call it, information (there’s some discussion of this in the awkward situations this distinction produced) — on local customs, relations between local leadership, and the little things that can really mess up inter-cultural communication (like an American soldier talking directly to an Afghan woman of the house).

What convinced the military that they should forge alliances with pointy-headed academics? Well, Hodge describes the source as an article by a policy fellow at the Office of Naval Research, Montgomery McFate, published in Military Affairs in 2005. Anthropology and Counterinsurgency: The Strange Story of their Curious Relationship argued that the military should bring in anthropologists and other social scientists in order to serve their new nation building objectives.

Once called “the handmaiden of colonialism,” anthropology has had a long, fruitful relationship with various elements of national power, which ended suddenly following the Vietnam War. The strange story of anthropology’s birth as a warfighting discipline, and its sudden plunge into the abyss of postmodernism, is intertwined with the U.S. failure in Vietnam. The curious and conspicuous lack of anthropology in the national-security arena since the Vietnam War has had grave consequences for countering the insurgency in Iraq, particularly because political policy and military operations based on partial and incomplete cultural knowledge are often worse than none at all.

Essentially, McFate was arguing that in order to succeed militarily against a counterinsurgency, the military had to improve its cultural competence. (There really are too many cynical comments to make at this point — I will refrain… but feel free to contribute in the comments section below.)

Hodge writes well, and he refrains from the holier-than-thou commentary that has become typical in critiques of the US’s blunders in Iraq and Afghanistan. His history is well-sourced, and much of the book is built on his own, first-hand, reporting. Put this on the required reading list for humanitarian aid workers, and maybe for soldiers too.

Globally, the report tells us that there were 358,800 new asylum applications worldwide in 2010. This is down 6% from 2009 (378,360, for those of you counting), but with asylum cases (which are legal cases often adjudicated in underfunded immigration courts) often going on for two years or more, it doesn’t tell us how many asylum seekers there are total at any given time. That number is usually estimated at around 850,000 (though that number may be a little dated).

What’s notable about this year’s report is the origin of new asylum claims. As one would expect, conflicts that have lessened in the past year are “sending” fewer asylum seekers — for example, Iraq fell from the top asylum claim country in 2006-2008 and number two in 2009 to number 4 in 2010, or 6% of new claims worldwide. Can you guess what country was number one? Afghanistan? Nope: number two. The number one source of asylum seekers in 2010 was… Serbia.

Serbia? Yes, the number one country from which new asylum seekers fled in 2010 was Serbia. This represents a 57% increase over asylum seekers from Serbia in the previous year. Serbia was, of course, the primary aggressor in the Balkan conflicts of the 1990s, but things have been quiet recently… so why this increase? Well, it turns out it has not so much to do with any new round of ethnic cleansing as it does with European Union policy. It turns out Germany was the country where most of these migrant claimed asylum, and the report has the following to say about it:

Germany was the third largest recipient of applications among the 44 countries, with 41,30o new asylum requests registered during 2010. This is a 49 per cent increase compared to 2009 (27,700 claims)and the highest value since 2003. The increase in 2010 is partly attributed to a higher number of asylum-seekers from Serbia and The former Yugoslav Republic of Macedonia, many of Roma origin. This may be the result of the European Union having waived visa requirements for both countries at the beginning of 2010.

The flight among Serbian Roma to Germany belies a larger truth about asylum seekers: they seek asylum in countries with healthy economies. In fact, if you look at the ranking of countries by number of new asylum claims and then look at the ranking of countries by asylum seeker to Gross Domestic Product (which is provided by the report for 2006-2010), they are almost identical:

2010 claims     Claims by GDP 2006-2010

1. United States         United States

2. France                     France

3. Germany                 United Kingdom

4. Sweden                    Sweden

5. Canada                    Canada

And if you were wondering, numbers six are the United Kingdom and Germany, respectively, rounding out the list. That’s all countries with robust economies. We often think that the defining experience of asylum seekers is flight from persecution, but that is only half of the story. Very often one form of persecution or result of destabilized societies is a lack of viable employment opportunities. People flee to somewhere, and that somewhere is not arbitrary — it is based on the perceived chance of a new, better livelihood. Very often forced migrants are also economic migrants. Whether the reverse is true is open to debate.

Well, at this point there isn’t much in the way of specificity given surrounding psychosocial support. The UNICEF appeal lumps them together with “family tracing and reunification,” a critical service aimed at connecting family members who have been lost in the flight from danger. The appeal adds that “UNICEF will provide booklets for psychosocial support” and “recreation kits.” The IFRC notes that in addition to the target population, staff and volunteers will be provided with psychosocial support as well — this sounds good, but tells us little beyond the (important) fact that the IFRC is aware that burnout is a threat to people who work with displaced populations.

Another IFRC update (from March 4th, 2011), this one detailing the Libyan Red Crescent’s work, is more specific:

Volunteers are providing psychosocial support to help people overcome the difficult and desperate situation they have suddenly found themselves in. They have enabled people to make phone calls to their families and loved ones, and assisted them with travel arrangements within and outside Libya, including transport to the Libyan border, the transfer of belongings, and the facilitation of travel procedures with the authorities.

So here we have the elements of “psychosocial,” at least in the first stages of a refugee crisis: maintaining family networks and facilitating orderly travel so that the events that led to displacement do not lead to the disintegration of the supportive social structures that allow human beings to cope effectively with their situations. This emphasis on the social bonds, the social networks that are so easily damaged during wartime, is the essence of psychosocial.

PS: UNICEF makes special mention of relying on regional teams, noting that the country offices in Egypt and Tunisia “have solid expertise around child protection and psycho-social support.” Kudos for UNICEF for being explicit about going local.