Archive for the 'public health' Category

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.

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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.

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.

Brain-mind or heart-mind; TMS or MST; DSM-5 or DSM-V? The American Psychiatric Association in New Orleans

This weekend and the first part of this week the American Psychiatric Association held its annual meeting in New Orleans, LA. In addition to staying out of the way of drifting gulf oil and seeing a lot of great music, I sat in on a few sessions in the monstrous Morial Convention Center to hear the latest from my psychiatric cousins. Psychiatrists in general fascinate me. On the one hand they rely heavily on the biomedical model to explain psychological phenomena (they are, after all, doctors), on the other they talk even more impressionistically than my psychologist compatriots (one of the presentations this year is on Chopin). As doctors, they know so much stuff (doctors have to memorize an amazing number of facts about the body), yet as researchers they can hardly handle more than two-by-two tables in their analyses (to be honest, most psychologists don’t do a whole lot better — they just don’t get published). I get asked all the time whether I’m a psychologist or a psychiatrist, and then, regardless of the answer, if I can prescribe; for those of you wondering: psychologist, and no.

On Saturday, I attended a session run by Devon Hinton (of Mass General) on cultural assessment of non-Western patients. In addition to Devon, his brother Ladson, Roberto Lewis-Fernandez, and myself, Brandon Kohrt of Emory University presented a paper on culture and symptoms. Brandon’s done a lot of work with child soldiers in Nepal, and presented on “child-led indicators” of distress among this population. Lots of good things in there, but my favorite was a distinction made among Nepalis between problems of the “brain-mind” and problems of the “heart-mind.” Your heart-mind is where your emotions are, your brain-mind where your thinking and cognition happen. Heart-mind problems are normal, brain-mind problems stigmatized. Although heart-mind problems can lead to brain-mind problems, they usually can be addressed successfully with appropriate social support. Critically, Brandon reported that Western psychosocial NGOs working with Nepalis affected by the civil war (which ended in 2006) had translated posttraumatic stress disorder into a term associated with brain-mind problems, and thus found it very hard to get people to participate in their interventions. It was only when they started using a heart-mind term that they got more people to participate.

TMS stands for transcranial magnetic stimulation. MST stands for magnetic seizure therapy. I’ll admit here that I am way out of my league here, but I’ll give you the synopsis. Both are new treatments for depression, and both involve magnets applied to your skull (falling under the somewhat euphemistic category of “brain stimulation”). In TMS you are awake, in MST you are under anesthesia. Okay, why do you want to do either of these things? Well, the treatment with the strongest therapeutic effects on people who have suffered multiple bouts of severe depression is well known to be electroconvulsive therapy, ECT. Yes, that means administering electric shocks to people’s brains. The problem with ECT is that associated with shocking people’s brains is some retrograde amnesia. So, electrotherapists have searched for more focal treatments at lower doses, and have found some success by putting strong magnets on the surface of people’s heads. I’m being a bit glib here, but really, this is pretty exciting stuff — particularly for those suffering from depression that is resistant to medication. For more on TMS, see the work of William McDonald; for MST, see Sarah Lisanby (she’s also done TMS work as well).

The development of DSM-5 was a big topic at APA 2010. The publication of the DSM-5 in May of 2013 (at APA San Francisco) is already a much-heralded event, and those on the various subcommittees have been doing due diligence throughout the various mental health conference circuits. I heard a lot about DSM-5 at APA 2010, but perhaps the most interesting proposed conceptual change I heard was the decoupling of disability from the notion of mental disorder. Since DSM-III (1980), criteria for diagnosing most disorders has included a functional criterion; i.e., you can’t just have some symptoms, the symptoms have to keep you from doing the things you want or need to do. So, someone with depression who is really sad but gets everything done cannot really have clinical depression. Decoupling symptom criteria from functional disability would put DSM-5 in line with the World Health Organization’s ICD-10/ICF system (ICD-10 is the WHO’s classification disorders manual; ICF is their functional disability manual). It would also clearly expand the number of people with disorders, as the functional criterion limits the application of a given disorder. Over-diagnosis will likely result. However, leaving things as they are means that the functional criteria limits prevention efforts: if you have to wait to diagnose a disorder before it becomes disabling, how can you administer (or more to the point, how can you pay for the administration of) prevention efforts? Stay tuned… or just check out the DSM-5 website. (By the way, it’s settled: DSM-5, not DSM-V.)

Book review of Crazy Like Us on STATS.org

STATS is an organization that examines the reliability and validity of quantitative findings in social science and medicine for laypeople, specifically journalists. Today they feature a book review of Ethan Watters’ Crazy Like Us: The Globalization of the American Psyche, by none other than yours truly. Here’s a teaser:

those of us who work in the small corner of mental health research that examines the differences in diagnoses and symptoms between cultures are somewhat surprised by Crazy Like Us; our field, generally, remains well hidden in the crease between psychology and anthropology. That our first popular treatment should be a highly critical survey of this field of mental health is doubly shocking.

Keep reading, here .

Vikram Patel at NYU, and a genuine global mental health agenda

Last Friday, March 6, the good folks at NYU’s program in Global Public Health hosted a lecture and discussion with global mental health luminary Vikram Patel. Dr. Patel is one of the forces (perhaps the driving force) behind the field of global mental health, and one of the architects of the Lancet’s series on the subject in 2007. This relatively new field combines public health, cross-cultural psychology, and human rights, and seeks to expand concern for mental health disability from it’s purview as a Northern luxury into a worldwide movement. For more general information on the topic, visit www.globalmentalhealth.org.

Dr. Patel’s talk at NYU was largely a call to action, as opposed to an empirical evaluation of the field’s successes and failures to this point. This is not to his discredit; Dr. Patel knows of what he speaks. From his groud-breaking work on Shona idioms of distress in his native Zimbabwe to his more recent clinical trials of community health workers’ delivery of mental health services in his family’s homeland India, Dr. Patel is well-steeped in several of the field’s parent disciplines. But Friday’s purpose was to spread the word. Lauding the success of the HIV/AIDS public health movement, Dr. Patel called on public health workers — or at least the public health trainees present — to take up similar strategies to convince public officials and other healthcare workers that mental health must be a priority in the developing South as well as developed North.

As for research, Dr. Patel noted that 90% of mental health research is done in the developed North (and within that, most in the US), and insisted that that must change. Research must guide practice in order to avoid the mistake of simply applying US or European models elsewhere. Along these lines, he pointed to recent funding interest in global mental health, even by the US’s NIMH (specifically, a recent blog post by director Thomas Insel titled “Disorders without Borders” — good grief!), a research body not known to fund many international projects.

This brought a question from the crowd (well, actually a question from me): If 90% of the mental health research is done in the developed North — the place where academics have the technology, funding, and financial interests to do research — and more research needs to be done in the less developed South, how should this be accomplished without running roughshod over local explanatory models of mental distress and local service models that may do some good? Dr. Patel acknowledged that this was a major concern, and provided the following solution: work with and teach local practitioners to do the research.

This simple-sounding solution is actually a tall order. The money and research technology (and here I’m talking about specialized research training as well as computer software) is in the North. The academic motivation for high-quality research is also largely Northern — “publish or perish.” It’s hard to see how NIMH-funded research would not evince a preference for US-led projects. So at the moment, beyond projects that hire locals to collect data, it’s hard to find projects that really substantively involve local ideas and researchers and people schooled and based in the research-resourced North (like the students at NYU last Friday). But there are a few — although very few — projects that fit the bill.

The first is Patel’s own work. Although he holds several professorships throughout the Europe and North America, he is based in Goa, India, and his research is there, and includes local staff. However, until more Vikram Patels arise (which won’t be too long, I think), his remains a special case of a culture-spanning researcher, trained in Northern/Western models and adapting, applying and distributing them throughout the developing world.

The best example of a US-led project is a USAID-funded program out of the Center for Victims of Torture (CVT) in Minneapolis, the International Program Evaluation Collaborative, or IRPEC. The brainchild of Jon Hubbard, the Research director at CVT, IRPEC aims to transfer the technology of empirical research to NGO’s working in mental health and human rights around the world in order better collect and analyze data to improve their services (and, of course, to get grants from Northern foundations which require such information). At this point I should probably disclose that I was an evaluator for IRPEC this past summer (see entries on Cambodia and Peru for related material), and that I was pretty impressed.

During this evaluation Jon told me a story of meeting a researcher who evaluates such programs who asked him, “Okay, but where’s your data?” Jon replied, “It’s not my data. It’s their data.” Until we can take up Hubbard’s example, those of us in the North who work in global mental health will always be in danger of “getting it wrong” — both ethically as well as empirically — in our quest to answer Vikram Patel’s call.


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