Archive for the 'Vikram Patel' Category

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.

NIMH, LMICs, & CHIRMH: Funding for global mental health research

Back in March of this year I wrote about Vikram Patel’s call for more international mental health research:

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.

Since then the National Institutes for Mental Health (NIMH) has come up with more than just ominous blog titles. As I was trolling program announcements (“PAs” — the mechanism by which the National Institutes of Health says to researchers what they are really interested in paying for) earlier today I stumbled across several intended to fund research outside of the global North (that’s North America and Europe), or in the language used in these PAs, “LMICs” — “low- to middle-income countries.” Most of these were offered in a variety of funding amounts, from $50,000 to $250,000 (US dollars) per year over 2-5 years.

Here a a few. There’s the basic public health PAR-10-278: Global Research Initiative Program, Basic/Biomedical Sciences, intended to

promote productive development of foreign investigators from low- and middle-income countries (LMICs), trained in the U.S. or in their home countries through an eligible NIH funded research or research training grant/award.

For neurologists there’s PAR-11-031: Brain Disorders in the Developing World: Research Across the Lifespan, which

encourages exploratory/developmental planning grant applications proposing the development of innovative, collaborative research and research training projects, between high income country (HIC) and low- to middle-income country (LMIC) scientists, on brain and other nervous system function and disorders throughout life, relevant to LMICs.

There’s even an ethics PA: PAR-10-174: International Research Ethics Education and Curriculum Development Award,

applications from institutions/organizations that propose to develop masters level curricula and provide educational opportunities for developing country academics, researchers and health professionals in ethics related to performing research involving human subjects in international resource poor settings.

(Not a bad idea for folks in the North involved in international research either, I might add.)

By far the biggest news among these titles is the new RFA-MH-11-070: Collaborative Hubs for International Research on Mental Health (U19). “U series” grants (look at the “U19” in parentheses at the end of the title) are meant to pay for academic infrastructure — scholarly institutes and centers that produce a lot of research and are thought to be indicators of universities’ general research prowess. Here’s the full “purpose” section:

The National Institute of Mental Health invites applications to establish Collaborative Hubs for International Research on Mental Health (CHIRMH).  This program aims to establish three regional hubs to increase the research base for mental health interventions in World Bank designated low- and middle-income countries (LMICs) through integration of findings from translational, clinical, epidemiological and/or policy research.  Each regional hub is to conduct research and provide capacity-building opportunities in one of six geographical regions (i.e., East Asia and the Pacific; Europe and Central Asia; Latin America and the Caribbean; Middle East and North Africa; South Asia; Sub-Saharan Africa).  The purpose of the CHIRMH program is to expand research activities in LMICs with the goal of providing the necessary knowledge, tools, and sustainable research-based strategies for use by government agencies, non-governmental organizations, and health care institutions to reduce the mental health treatment gap.  The mental health treatment gap refers to the proportion of persons who need, but do not receive care.  As a group, awardees will constitute a collaborative network of regional hubs for mental health research in LMICs with capabilities for answering research questions (within and across regions) aimed at improving mental health outcomes for men, women, and children.

The treatment gap for mental disorders across the world is large and leads to chronic disability and increased mortality for those affected.  Research is needed to identify effective treatment and prevention strategies to close this gap. Mental health research that ultimately enables effective services to preempt, prevent, and treat mental disorders requires both infrastructure and partnerships.  Tackling the urgent challenges of the treatment gap demands effective collaborations among researchers, mental health service users, mental health service providers, and government agencies that will implement and sustain services.  Therefore, a goal of this FOA is to support research partnerships and activities in LMIC settings that will stimulate research to address the prevention and treatment of mental disorders and ultimately increase the evidence base for mental health interventions.

Notably, the PA states that “This program is not intended to support research that can be conducted primarily in and/or by United States or other high income country institutions.” This has the potential to be the start of something big, a US-funded development effort for global mental health. The NIMH is committing $2 million to this effort in 2011, and applicants are eligible for awards up to $500,000 per year for up to 5 years. (Letters of intent are due December 21 and applications due January 21, 2011, for those of you thinking about applying.)

Getting better v. being better: Wellness, Positive Psychology, and morality in mental health

The New York Times Magazine this weekend is a special issue on the science of healthy living, and in the On Language column (a weekly entry on etymology — that’s words, not insects) Ben Zimmer covers derivation of “wellness.” I haven’t entirely recovered from the absence of Bill Safire’s wordly genius (1929-2009; Safire was the On Language columnists for almost that long), but I do peek at the titles now and then. “Wellness: How did we end up with this alternative to ‘health’?” caught my eye. I read it, and was struck by the language of morality in the article.

Consider the following description of Halbert L. Dunn’s “high-level wellness”:

an integrated method of functioning, which is oriented toward maximizing the potential of which the individual is capable.

Maximizing potential? In the medical context of this week’s On Language, this sounds like getting really buff. But wellness is used frequently in psychology as well, and talk of maximizing potential hearkens to Rogerian self actualizing potential (Carl Rogers practiced unconditional positive regard in order to unleash clients’ self actualizing potential) and other key concepts from humanistic psychology. Modern psychology’s has an updated version of this in the booming field of happiness studies and Positive Psychology.

Positive Psychology is based around the idea that psychology should examine the non-pathological phenomena of the human condition. In this way it’s a sort of “anti-Abnormal Psychology.” Okay, that’s nice; who doesn’t like a “strengths-based” approach? A criticism of Positive Psychology is that it often infuses the language of morality into its key concepts. But is it really morally prescriptive? Let’s ask the experts.

Here’s a quick answer from the FAQ section of the Martin Seligman’s University of Pennsylvania’s Positive Psychology Center:

5. Is the science of positive psychology descriptive or prescriptive? In other words, are we trying to tell people how they should live?

Positive psychology is descriptive, not prescriptive, at least in Seligman’s view, although others disagree. We are not telling people which choices they should make; we are merely informing them about what is known about the consequences of their choices. The good life for one person is not necessarily the good life for another. Objective, empirical research on the conditions that lead to different outcomes, however, can help people make more informed choices, but we take no theoretical stand on the desirability of the different choices.

Hm, I guess it’s not. So…. here’s a couple non-prescriptive titles from Seligman: Authentic Happiness: Using the New Positive Psychology to Realize Your Potential for Lasting Fulfillment (2002); Character Strengths and Virtues A Handbook and Classification (2004). A handbook of “virtues” takes “no theoretical stand on the desirability of… different choices”? Really?

The fact is that health and wellness of any kind inevitably involves moral judgment, and as such their practitioners are often called upon to act as experts in morality. But we in mental health are not well-trained in morality — I’m not saying we’re a bunch of jerks, just that most of us don’t get training in ethics beyond learning our respective professional codes of ethics (which are, by the way, are mostly limited to specific things we shouldn’t do — e.g., don’t sleep with your patients, unless two years have passed since the end of treatment — and a few vague pronouncements about overarching principles — e.g., treating or referring everyone who seeks treatment). We would do well as a field to further examine how the “shoulds of getting better” bleed into the “shoulds of being a better person”.

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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