Archive for the 'psychosocial programs' 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.

Advertisements

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.

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.

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.

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.

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.

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.


October 2017
M T W T F S S
« Apr    
 1
2345678
9101112131415
16171819202122
23242526272829
3031