Posts Tagged 'refugees'

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.

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.


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.

37 year-old refugee crisis comes to an end

Where do refugees go after the crises that made them refugees leaves the headlines? The options are: go home, get resettled to a wealthier country, stay in the camps.

The UN estimates that at the end of 2008 (the last year there are reliable numbers for at the moment) there were 15.2 million refugees in the world (a refugee here is a person who has fled across a border because of political violence). Eighty percent of these refugees, or about 12.2 million, lived in camps or urban areas in neighboring countries in the developing world (e.g., the 1.8 million Afghans in Pakistan).

Some refugees go home. How many? In 2008, 600,000 refugees went home; 600,000 / 15.2 million = 4%. This was the lowest number since 2004, suggesting that going home is less and less an option.

What about all the refugees resettled in wealthy Western nations? In 2008, 121,000 were proposed for resettlement to wealthier nations (US, Canada, and Western Europe, primarily), or 0.8% of all refugees at the time.  Only 67,000 of these were actually resettled, about 0.4%.

So, most refugees remain in camps and foreign cities for very long periods of time as refugees. Surely there must be some other plan. Well, recently UNHCR has been proposing a policy of “local integration.” Local integration means what it sounds like  — making refugees part of the local economy and society of the region in which they live, with full citizenship rights and privileges, and no more refugee aid. The involves getting local governments to accept that refugees they have played host to for years are there to stay, and getting the refugees themselves to accept that they cannot receive aid forever. This long-term solution is usually pretty long-term. In Chad, the UNHCR started encouraging local integration for refugees from the Central African Republic who had been there for 1o years.

One of the oldest refugee populations are Burundians in Tanzania. Burundi is now infamous for ethnic conflict in 1994 (similar to neighboring Rwanda’s), but many Burundians in Tanzania are there because they fled from massacres in 1972. In other words, these Burundians have been sitting in camps for 37 years. This week, Refugees International reported that last month Tanzania gave citizenship to 162,000 of these Burundians. This is a welcome and generous move by Tanzania, a country that has been host to several large refugee populations — the price of being a peaceful place in a dangerous neighborhood.

(162,000: That’s 1% fewer refugees, for those of you counting.)

April 2017
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