Posts Tagged 'displaced populations'

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.

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.

The HESPER: WHO’s measurement answer to the problem of identifying needs within displaced populations

The World Health Organization recently released the Humanitarian Emergency Settings Perceived Needs Scale (HESPER), a measure that they hope will operationalize the IASC Guidelines on Mental Health and Psychosocial Support in Emergency Settings and encourage rapid assessment of perceived needs in disaster settings. Longtime disaster mental health and psychosocial researcher Mark van Ommeren was the lead on the project, which means that it was developed with the highest level of rigor given the needs, which include some flexibility. A large advisory group that reads (with a few exceptions) like a who’s who of international disaster mental health and psychosocial intervention provided regular input, and the HESPER was tested in sites as various as Sudan, the UK, Jordan, the Palestinian Territories, Haiti and Nepal. Overall the psychometrics reported look good, particularly given the diversity of locations. There are sections on individual needs and community-level needs on a surprising number of domains, a welcome relief from the unidimensional individual-level norms.

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.

Article supplement: Posttraumatic idioms of distress among Darfur refugees

The September 2011 issue of Transcultural Psychiatry is out, and it includes an article by myself and some colleagues based on some work we did with Darfur refugees a few years ago. Publication lag times as they are (a colleague this morning compared them to the aging of fine wines), by the time an article is finally comes out in print the author’s ideas about what he/she sees as the “take-home” message may have shifted slightly. So here’s my chance to provide the 2011 take-home to a study written in 2009.

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.



							

Serbians fleeing to Germany? The 2010 UNHCR report on asylum seekers

The United Nations High Commissioner for Refugees has just come out with its 2010 report on asylum seekers. Asylum seekers are a particular class of forced migrants who are seeking protection from being sent back to their home county but whose refugee status has not yet been determined. In other words, where refugees are resettled by governments, asylum seekers resettle themselves. The UNHCR report is compiled from statistics provided from 44 industrialized countries, mostly countries in North American and Europe (not to slight Australia, New Zealand, Japan and South Korea).

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.

Psychosocial support in Libya: What it looks like in the first weeks of a crisis

Although barely a few weeks old, the crisis in Libya has already set the NGO world’s psychosocial intervention machine in motion. Appeals and updates from UNICEF, the International Federation of the Red Cross and Red Crescent Societies (IFRC), and Handicap International from last week have put psychosocial support up front and center (along with clean water, food, and shelter) in operations in Tunisia and Egypt and even in western (i.e., opposition-controlled) Libya designed to aid people fleeing the fighting. So just what does this psychosocial support entail?

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.

Blogoshpere updates from the Darfur crisis

A couple notable developments from the Darfur. The first is a news item (hat tip to Gabrielle Grow of the Institute for War and Peace Reporting office in The Hague, Netherlands), the Sudanese government is relocating thousands of IDPs within Darfur because of security concerns:

The recent turmoil started in late July when demonstrations by opponents of peace talks with the government turned violent. Backers of the Sudan Liberation Army, SLA, clashed with supporters of the talks currently taking place in Doha. Several deaths were reported in the violence.

“The problem is that weapons are flowing all over the place, not just in the camps but outside,” Russia’s UN ambassador Vitaly Churkin, who currently chairs the Security Council, said following a meeting on the situation.

The Sudanese government says the planned move is being undertaken for security reasons as well as because of the camp’s proximity to an airport and railway lines.

The second is a study undertaken last year of displaced Darfur refugees  (in Chad) carried out by the group 24 Hours for Darfur.

The US-based non-profit research organization spent four months in the 12 Darfurian refugee camps in eastern Chad, interviewing 1872 randomly-sampled civilians and 280 civil society and rebel leaders. The data gathered from the civilian sample is representative of the adult refugee population in Chad, and sheds light on important questions about participants’ specific beliefs about the root causes of the conflict, past peace negotiations and agreements for Darfur and southern Sudan, the nature and importance of justice in bringing about a sustainable peace, the possibility of reconciliation, land-related issues, democracy, power-sharing, and the national elections, and which actors, if any, best represent their views.

I was in Chad at the same time as the folks who put this project together. They had assembled an impressive group of interpreters and interviewers (so impressive, in fact, it was tough to find good interpreters for anyone else!). Connect to the report via Jonathan Loeb’s blog (Jonathan was one of the organizers of the study).

A “daily stressors & trauma” debate & the temptation of mental health evaluation for everything

In a special issue on “Conflict, violence and health” earlier this year, Social Science and Medicine published an editorial on trauma-focused versus psychosocial perspectives in humanitarian aid that Ken Miller and I wrote (see my blog post from June 29th, 2010 for related material). This week the second October 2010 issue of the same journal includes a critique of our editorial from the accomplished refugee trauma researcher Frank Neuner and our response to this critique. Lest you think that publishing a second October issue in mid-September is the sign of general silliness, let me inform you that (1) the virtual world resides somewhere in the future, and (2) Social Science and Medicine consistently publishes high-quality health research and — notably — debates (like ours) in subfields that could use a healthy does of academic energy.

Our debate primarily concerns how best to provide “psychosocial” and “trauma-related” mental health services to displaced populations (i.e., refugees). The three articles are a somewhat academic read (all of us are, after all, academics), but I would not say that the topic is purely academic. Psychosocial aid and trauma interventions are hot topics in humanitarian aid, and agencies’ perspectives on these issues has direct relevance for the design of programs in the field.

I won’t repeat the detailed back-and-forth here, as you can read the articles yourselves (if you have trouble accessing the links above please let me know). I do, however, want to highlight one important point of agreement. Even though we reiterate this point in our response, I think Neuner says it better in his critique of the editorial:

Reducing hardship and daily stress is without a doubt a key objective of humanitarian assistance. No one would disagree that increasing security in refugee camps, improving child protection and medical care, reducing violence and poverty, increasing awareness of gender issues, and reducing discrimination should be high priority goals that deserve much attention by humanitarian agencies. The respective programs should clearly state their goals and be evaluated according to their specific aims. However, it is premature to claim that such programs heal psychological disorders or foster mental health. The increasing tendency to justify widespread programs on the basis of mental health is worrisome and seems to reflect the tendency to comply with donors’ fashions. Why must a program that aims at reducing discrimination of former child soldiers also improve mental health? Reducing discrimination, just like improving development and reducing violence is a worthy objective on its own right.

The increasing tendency to judge interventions in refugee camps — even interventions with the label “psychosocial” — solely by examining rates of psychiatric diagnoses pre- and post-intervention is indeed a problem. Having participated in such evaluations, I can attest that apart from the considerable cross-cultural assessment issues and challenging diagnostic environment, these efforts leave me with the sinking feeling that many in humanitarian aid have succumbed to the temptation of scientific — or perhaps better put, “scientistic” — validation. In other words, evaluations that were specific to specific programs (e.g., measuring change in social and economic indicators in order to judge child soldier reintegration programs) became mental health evaluations (measuring reductions in anxiety in order to judge child soldier reintegration programs), thereby getting the stamp of approval of medical science. This curious turn of events has meant that many programs (at least those not directly tied to food, water, and other basic needs) are now “sold” to donors in the language of mental health, even though they may working towards some other — also worthy — objective.

Stressors, more stressors, and blaming the victim in wartime

Those people who dedicate their lives to addressing stressors among displaced populations are frequently faced with an uncomfortable truth: people under a lot of stress sometimes create more problems for themselves. This is a well-observed phenomenon across populations, and is generally known as “stress generation.” As regards trauma work, there is good research to show that the best predictor of future trauma is past trauma. For those of you not well-versed in stress generation, see Constance Hammen’s reflection on her career researching stress generation among depressed individuals in the Journal of Clinical Psychology.

The uncomfortable part of all this is that it can move quickly into “blaming the victim” (particularly as it pertains to trauma). If a combat veteran presents with PTSD and marital conflict due to the irritability and anger that is a part of the PTSD diagnosis, it can be very difficult not to get really frustrated with that vet’s anger and sink into “it’s your own damn fault” despite our initial sympathy. An automobile accident survivor has a higher likelihood of getting into another automobile accident than someone who hasn’t been in an automobile accident because the survivors tend to be extra cautious following their first accident, drive more slowly at the wrong times, get distracted by other drivers, etc.; if these things cause an accident, who is responsible?

When it comes to refugees, blaming the victim may result in less critical aid from the international community and stigma upon resettlement. And yet it’s clear to anyone who’s worked in refugee camps that a stressed population is a difficult population is difficult to work with. Indeed, one of the impetuses behind bringing psychosocial interventions into humanitarian aid is the danger that stressed refugees can pose to aid workers. There are numerous reports of refugees striking out against aid workers for small irregularities in aid distribution or changes in policies. (I should add that their are also striking reports of other refugees coming to the aid of aid workers.)

So how do we reconcile stress generation with our discomfort? Well, first by reminding ourselves that the first order of health provision is not morality. (I’ve harped on that before, and you probably don’t need to read it again here.)

Second, by looking further into stress generation research so we know what we’re talking about. In this literature, folks like Hammen make the distinction between “dependent, interpersonal” stressors and “independent, fateful” stressors. It turns out that research with people with mental health diagnoses have (on average) more stress-dependent events than people without mental health diagnoses, but have the same number of independent events. Dependent events are almost uniformly interpersonal in nature — and therefore plausibly related to how one would act towards others if really stressed. Independent events may be interpersonal, but their core feature is their fateful nature — they are not affected by how someone is acting.

How does the dependent-independent dichotomy map on to the typology of conflict-related stressors proposed in the last entry in this blog? Well, it’s pretty clear that mental health problems aren’t to blame for people being attacked or cause them to end up in unstable resettlement contexts — this is the “direct war exposure potentially traumatic events (PTEs)” category. For “collateral” and “other PTEs” (which, as I think through them may not be as distinguishable as they first seemed), the picture is less clear, and that some of these stressors are related to “being stressed” means that education campaigns surrounding the affects of stress (at the very least) are important. “Social ecological stressors” are clearly set off by displacement, but the breakdown of community institutions may be exacerbated by interpersonal problems. This is why the “social” in “psychosocial intervention” has always struck me as the more important of the two traditions. “Daily hassles” are likewise split between those problems that are outside of the control of the individual (e.g., a military checkpoint) and those that are exacerbated (unemotional reactions to hearing of abuse of loved ones). So perhaps the dependent-independent dichotomy is a second axis that runs through the typology proposed a few days ago. (Again, comments encouraged here.)

Important to remember through all of this is that all of these stressors are precipitated by an initial event — the event that was the cause of displacement. It would be difficult to argue that displacement events were dependent stressors. And yet many subsequent stressors, be they mild or traumatic, are dependent to some degree. In order to address these, humanitarian aid workers must remember the latter, and the former; they are equally important.


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