Archive for the 'humanitarian aid' Category

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.

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.

Looking for graduate school applicants for research in forced migration, trauma and stress at Fordham University

Fall is graduate school application time, as many programs have application deadlines in October, November and December. I have recently moved to Fordham University’s Department of Psychology, and will be looking for graduate student applicants to the Clinical Psychology Division for the 2013 cohort. If you read this blog you know my experience and general research interests, so you know what kind of student researchers I am looking for. Current research projects include comparing the social networks of forced and voluntary immigrants and the health and mental health implications of network differences, measuring trauma and stress in different culturally-defined subgroups, and community-based participatory research with immigrant populations in general. If those are topics that interest you (and you want to get a PhD in Clinical Psychology), follow the links on the Clinical Psychology website and apply.

Deadline for 2013 applicants is Wednesday, December 5, 2012.

If you are not sure you want to commit to a PhD, but know that you are generally interested in psychology, program evaluation and related skills, please visit Fordham University’s MS in Applied Psychological Methods page. Fordham’s APM program is a relatively new course of study that draws heavily on it’s well-respected Psychometrics and Applied Developmental Psychology divisions within the Department of Psychology. Admissions are “rolling,” meaning that you can apply at any time and start the following semester. Students can be full- or part-time.

More evidence that measuring local concepts of distress matters

The latest issue of Psychological Assessment includes an article by University of Pennsylvania postdoctoral research fellow (and soon to be Manhattan College Assistant Professor) Nuwan Jayawickreme that provides support for the use of locally developed distress measures in post-disaster settings that are beyond the cultural boundaries of Western psychology’s usually realm. Are Culturally Specific Measures of Trauma-Related Anxiety and Depression Needed? The Case of Sri Lanka provides empirical evidence suggesting that once locally-developed measures of posttraumatic distress are administered, administering measures of PTSD and depression (as defined by DSM-IV) does not provide any more useful information vis-a-vis an individual’s impairment of day-to-day functioning.

Developing psychological distress measures in non-Western disaster zones has been on the agenda of many in the disaster mental health field for over a decade now. The essential problem is that conceptualizations of mental health problems and the way that different people from different cultures express their distress vary widely. So, when mental health professionals need to assess individuals to see if they need treatment, they need a measure (questionnaire, survey, or some other standard measurement tool) that is sensitive to that population. How  are such tools to be developed? Jayawickreme explains:

Identifying such idioms first need to use ethnographic methods to understand how the social world interacts with the individual’s physical and psychological processes. Such ethnographic studies usually involve an in-depth examination of a specific culture’s conceptualization of a particular experience. Once the concepts and the idioms used by the community in question have been identified, questionnaires or inventories can be developed to assess these concepts, which are then validated using iterative statistical and field testing methods

And that’s what he did. And then he administered this measure, called the Penn/RESIST/Peradeniya War Problems Questionnaire (PRP-WPQ), the PTSD Symptom Scale (or PSS, a standard PTSD scale developed by trauma treatment luminary — and Jayawickreme advisor — Edna Foa) and the Beck Depression Inventory (the BDI, a standard measure of depression) to 197 Tamil Sri Lankans living in the war torn northern and eastern parts of the island. And then he looked at the incremental ability of the PTSD Symptom Scale and the Beck Depression Inventory to predict a measure of functional impairment.

Jayawickreme’s regression analysis showed what some of us have been talking about (and even publishing empirical results on) for a while now: Using measures of psychological distress with local populations that incorporate terms that they can understand is better at getting at the functional impairment due to this distress than using DSM-IV based measures.

The current findings provide support for the notion that sensitive measurement of  psychopathology in non-Western, war affected populations may require the development of instruments that incorporate local idioms of distress. As noted earlier, there are limited resources available for providers of psychosocial aid in non-Western, war-affected countries. Given the considerable needs of such populations, it may seem inappropriate to engage in what appears to be a costly and complicated process to develop measures incorporating local idioms of distress. The current results do indicate that the PSS and the BDI predict functional impairment to a substantial degree. However, the current results also suggest that measures incorporating idioms of distress may improve our ability over and above the established measures to identify those who are functionally impaired because of mental illness and who therefore need assistance.

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:


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.


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