Global Mental Health and Psychosocial Humanitarian Aid Final

Refugees

Displaced people who have crossed borders

Asylum Seekers

People who desire to become refugees

Stateless People

Typically, people who have had their nationality taken away

Sources of Stress for Populations of Concern

• war

• displacement

• lack of/issues related to identity

• food insecurity

• travel

• economic issues

• settling

Migration Process

Pre-migration → migration → post-migration

History of Refugees and Other Forced Migrants

• 1940s-1950s: reckoning with Holocaust

• 1951 UN Refugee Convention

• 1950s-1960s: small, mostly European refugee movements

• 1970s campaigns against torture

• end of Vietnam War and instability brought new waves of refugees

• 1980: DSM-III introduces PTSD

• Richard Mollica’s work on PTSD and depression in Cambodia

• 1980s-2000s: refugee research focuses on PTSD and depression

• Epidemiology of PTSD and depression

• research on asylum seekers in host countries pushed researchers to look at the effects of stressors in host countries

• Application of stressors to larger refugee populations

Limitations of Literature

1) Emphasis on exposure to crisis events at expense of other conditions, contexts, and protective factors

2) Over-reliance on non-validated symptom checklists

3) Variety of distress across culture rarely validated

4) Little attention to anything other than PTSD and depression

Social and Community Psychology

• not about psychopathology or stress and coping like clinical psychology

• social interactions

• community well-being

• overlap with social work traditions

MHPSS

Mental Health and Psychosocial Support; psychosocial support is “any type of local or outside support that aims to protect or promote psychosocial well-being and/or treat mental disorder”

Multimodal Psychosocial Model

1) basic services and security (socio-ecological interventions)

2) community and family supports (socio-ecological interventions)

3) focused, non-specialized support (community-based trauma counseling)

4) specialized services (community-based trauma counseling)

Core Principles of MHPSS

• promotions of human rights

• equity in availability and accessibility

• attention to avoiding unintended consequences

• active participation of affected population

• strengthening local resources and building on local capacities

Theories of Refugee Distress

• Conservation of Resources (COR)

• “Daily Stressors” Ecological Model

• Adaption and Development After Persecution and Trauma (ADAPT)

COR

• stress is caused by loss and/or the anticipation of loss

• all humans have a basic set of needs, some variation related to cultural meaning of resources

• loss often leads to loss spirals

• intervention should focus on supporting environments

Daily Stressors Ecological Model

• displacement is full of stressors that are not technically traumatic

• impact of displacement and trauma on stress is mediated by ongoing stress

• create supportive environments that reduce daily stressors, than can identify those with psychological disorders

  *chart

ADAPT

• conflict affects 5 core “psychological pillars” (safety, social bonds, justice, roles and identities, and existential meaning)

• allows interventions to focus on pillars that are most disrupted by conflict

  *chart

Trauma Focus

• trauma is the problem, PTSD treatment is the solution

• applying PTSD treatments in LMIC and refugee settings

• 2 characteristics of “best” models: assessment and RCTs

Treatment:

• seems to reduce symptoms of people with common mental disorders and trauma in short-term across a number of contexts

• can be “task-shifted”

• demands resources and time that may not be sustainable

• intervention is shown to work in readings and is necessary to look at practical aspects (environment) and have resource support (basic needs)

Clinical Assessment

• usually structured or semi-structured clinical interview (PTSD and post-traumatic stress symptoms)

• sometimes will include cultural constructs of distress

Randomized Control Trials

• challenges include unstable conditions (lack of food lack of housing, natural distress, etc.), comorbidity, language barriers, and social isolation

• experimental group: strict manualized treatment and treatment with guidelines

• control group: counseling or treatment as usual and waitlist control

• efficacious vs. effective (MHPSS cares about effectiveness)

Narrative Exposure Therapy

• exposure therapy plus narrative therapy

• first step is to build a timeline to identify “hot points”

  • acknowledging multi-trauma histories of many refugee stories

  • “hot points” are focus of exposure

• exposure therapy is a conventional imaginal exposure brief therapy

• reviewing worst “hot points” 3-6 times

• monitoring arousal during the recounting

• multiple RCTs in East African refugees

  • some European therapists

  • several task-shifted, locally trained practitioners

Frank Neuner

• Rwandan and Somali refugees at Nakivale in Uganda

• RCT with three “arms”

• both treatment groups were supervisors to monitoring alone, and no different from each other

Cognitive Processing Therapy in DR Congo

• trauma counseling for sexually assaulted women by IRC

• “probable depression, anxiety, and PTSD” based on screener

• emic inquiry and adaption of therapy

• CPT is an empirically-supported PTSD treatment in U.S. and Europe

• local MHPSS staff, lots of remote supervision

• 1 individual session and 11 group sessions

• randomization of 16 villages (excluding one) into two arms

• CPT vs. individual support and monitoring

• both groups got better

• CPT group got better more than individual group

• maintained at 6 months

RCT After Conflict in Colombia

• “Unified Protocol” targets neuroticism and emotional deregulation

• Colombia IDP

• PTSD 5.1x that of non-IDPs

• adapted for IDPs

• adaption

  • added an initial session for rapport and trust

  • text replaced with graphic material

  • involving patients’ own experiences as examples

• delivered by clinical psych grad students

• RCT study design

• fair number lost to follow up

• still large effect size differences

Testimony Therapy Buddhist Healing

• traditional context

• Khmer Rogue trials

• therapy designed for witnesses

• roots in 1970’s Argentina and Chile

• “testimony” both a psychological and legal act serving justice as well as well-being

IASC

• Inter-Agency Standing Committee

• try to integrate idea that there should be trauma focused interventions and community focused interventions

• people at UN who deal with refugees noticed discrepancy between people-focused on trauma treatment and others focused on broader approach (came up with agreements and guidelines to generate different activities to deal with stressors; also gave some new guidelines)

Critiques of Trauma Intervention

Psychological aspects: ongoing trauma; intervention as agitating clients

Practical Aspects: social support in isolating environments; resources

Critique of Psychosocial Programs

• if trauma is conceptualized as the main problem, PTSD treatment is the solution

  • but multiple other psychosocial problems may exist as well

Sri Lanka’s NGO Tsunami

• one village of 50 served by 27 NGOs

• waste of resources into one village rather than others

• practical issue

• also problem of ignorance

Kate Chaos

• uses play therapy to help children

• lacks psychological approach

• practical issue

• not culturally informed

• short-termed counseling programs

• represents well-meaning attitudes of psychologists from high-income countries who have poor planning

• problem of “savior attitude”

Seven Assumptions Behind Psychological Trauma Programs in War-affected Areas

1) Traumatization as a pseudo-condition

2) PTSD is the universal response to trauma

3) Large numbers need professional help

4) Best treatment is “emotional ventilation” and “working through” trauma

5) There are vulnerable groups that need targeting

6) Rapid intervention prevents mental health problems, even more war

7) Local worker are overwhelmed

Solutions:

• don’t treat PTSD

• look for/answer other problems

• don’t do pyschotherapy

Caregiver Support Intervention

• not explicitly trauma focused

• more than parent education

• used for Syrian refugees in Lebanon

• RCT showed benefits even under extreme stressors

• mindfulness exercises seem to be the most useful and sustainable (though not for some)

• emotional regualtion intervention

  *chart

Ethics

Set of guidelines that direct behavior of groups of people; ethics in aid are complicated given high income/low income differentials

4 Reccommendations to Do No Harm

1) critical reflection that involves local ethical perspectives

2) greater specificity for appropriate acts

3) better documentation of interventions that work

4) improved education for psychosocial workers

Individualist Orientation

• informed consent

• ethical issues

• nonholistic support

Deficit Focus

Conceptualizing people’s problems as problems

• deficit trap

• victimhood and empowerment

Capacity Building and Sustainability

• dependency

• poor training

• silo-ing with MHPSS

• subtle effects of power

• “crisis chasing” approach

Ethical Issues and MH Workers

• risks and problems of humanitarian aid staff

• 90% of humanitarian aid delivered by local staff

• burnout in local staff

• impact on post-NGO societies

Psychosocial Occupational Hazards

• repeated exposure to overwhelmed people

• situations with few positive options

• strained social support network

Three Psychological Conditions

1) Secondary Traumatic Stress (“contagious PTSD”)

2) Vicarious Traumatization (broader condition that includes other symptoms of anxiety and depression)

3) Burnout (emotional exhaustion, depersonalization, and lack of personal accomplishment)

Prevention of Workplace Stress

Recognition by NGOs and UNCHR of high-stress nature of work

• mandatory leave policies

• enforcing standards

• preparation for stressful working conditions

Institutional changes

• improving physical workplace environment

• clear decision making processes

• regular peer contact and support

Open Mole

• cultural concept of distress in Liberia

• vehicle of narrative of change from conflict to post-conflict mental health sector

• Healthworkers International (pseudonym for MH group in Liberia) used cultural concepts of distress for various diagnoses (Open Mole/anxiety, Open Mole/depression, Open Mole/schizophrenia, etc.)

• shifting and expanding meaning of Open Mole as linked to trauma because of HI’s practice

• local “psych team” in an ambivalent condition (still believed in validity of Open Mole, more than a symbol of MH disorder)

• paradox of cultural sensitivity and health system development

Implementation Science

The study of putting something into practice; examining programs’ outputs and outcomes

Kohrt et al.Study

How competent are non-specialists trained to integrate mental health services in primary care?

Findings: general improvement in knowledge, but less impressive in competence (role play)

Recommendations:

1) standardized measure of knowledge and attitudes (more research on stigma and attitudes in order to better select MH staff)

2) standardized measure of competency (standardized role play and observation measure of competency)

3) training and supervision should not rely on number of hours (rather, rely on attaining knowledge and competency)

High-income Individuals in Low-income Countries

• often occurs in MH programs

• differential access to resources

• role of incentives

• entry and exit

Summerfield

• critical of how humanitarian aid was done

• said that trauma treatment was not specific enough and too broadly applied (pseudo-condition)

• need to find who is suffering worse and know related factors for effective treatment (trauma is an event, not a condition

Deficit Focus

Looks at what’s wrong