A couple of colleagues and I recently published a review in Social Science and Medicine of the symptoms that are included in the various ways that different cultures think about the emotional distress following trauma. Our review included 55 studies and identified 116 different cultural concepts of distress. We categorized these concepts based on their symptoms (using hierarchical cluster analysis), and found that the 116 concepts could be described in four basic categories: (1) somatic dysphoria, which largely concerned bodily complaints; (2) behavioral disturbances, “odd” behavior (relative to cultural norms), (3) anxious dysphoria, which as its name implies included lots of anxiety; and (4) depression, which was surprisingly similar to depression as it appears in North American and European medicine. Notably, none of these groups of concepts looked like the psychological disorder that most mental health professionals in North America and Europe think of when they think about trauma — posttraumatic stress disorder, or PTSD.

Of course there are all sorts of limitations to our review, and some would argue that the way we categorized cultural concepts of distress using symptoms alone misses the point of the diversity of these concepts globally (which is broader concerning explanations for distress than it is concerning symptoms). Others would argue that PTSD is actually somewhere in the mix of concepts we reviewed. I’d like to think our review is a starting point for discussion of these issues, rather than a definitive answer to any of these questions.

You can find a link to the publication in Social Science and Medicine here.

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.

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.

What’s WEIRD? Western, Educated, Industrialized, Rich and Democratic. What’s weird about them? It turns out they… er, we… are probably the worst population to do psychological research with if you want to get a picture of the average human psychology. Read the paper here.

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.

IDP issues may, however, become a long-term issue. The sudden loss of material goods and social connections that people have based on where and how they live can have long-term consequences for social capital, employment opportunities, and even just knowing how to complete everyday tasks (e.g., where to get healthy food for your kids). The outpouring of support needs to be transformed into long-term engagement with IDPs, along the lines of the better psychosocial programs undertaken in more severe IDP crises (e.g., in Medellín, Colombia).

In the meantime, there has been a little attention to mental health. The best I have seen so far has been a post by “The 2×2 Project,” a blog written by Dr. Lloyd Sederer out of Columbia University’s Mailman School of Public Health. (A thank you to my wife, who forwarded me the link.) Here’s the intro, which sums up and corrects the myths that are often hears in immediate post-disaster environments:

In the aftermath of Hurricane Sandy, opinions—some reliable, some misleading— about the storm’s potential mental health impact have proliferated. When media channels act responsibly they engage experienced experts as spokespeople; when that does not happen, wrong information adds to the public’s anxiety and can foster inappropriate clinical interventions and waste resources.

In the latter category, perhaps the greatest myths I have heard are:

Post-traumatic stress disorder (PTSD) can appear in the immediate wake of a disaster.

Watching television can cause PTSD.

The highly common psychic distress in the wake of a disaster is a mental illness.

Here are some facts:

Psychic distress after a disaster, which can be highly prevalent and last up to a month, generally is a normal reaction to an abnormal situation.

Read the rest of the post (and check out other informative posts) here.

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.

Please see the following link for post-graduate fellowship experiences in global mental health delivery in Haiti and Rwanda through Harvard Medical School and the non-governmental organization, Partners In Health. This opportunity is now in its third year.

Information about the Fellowships and application links can be found here.

Although in the previous two years the fellowship has been filled by doctors, the director assures me that other Ph.D.’s would be more than welcome as well.

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.

Among the livelier presentations was a report by Roberto Lewis-Fernandez, Neil Aggarwal (both at Columbia), Laurence Kirmayer (McGill), and Renato Alarcón (Mayo Clinic and Universidad Peruana Cayetano Heredia) on much needed updates to the Cultural Formulation guidelines in the upcoming DSM-5. The DSM — Diagnostic and Statistical Manual — is the American Psychiatric Association’s official guidebook to human psychopathology, and the current version, DSM-IV-TR, is largely accepted as the last word on mental health problems in psychiatry, psychology, social work, and related disciplines. Cultural Formulation guidelines are suggestions for how clinicians should conceptualize the role of culture in patients’ mental health problems. The guidelines appeared first in the pages of the DSM-IV (1994), but, along with a short and messy list of “Culture-Bound Syndromes,” were placed in the back of the book where few practitioners would ever find them.

This time around there is a widespread effort to place the Cultural Formulation front and center in the DSM-5. Drs. Lewis-Fernandez and Aggarwal reported on a tool designed to make cultural formulation quicker and easier, the Cultural Formulation Interview, or CFI. The CFI is meant to be administered during patients’ initial assessment, and consists of 14 questions. Many of these questions are just good clinical practice. For instance, the first question is, “What problems or concerns bring you to the clinic?” Although there are hints at what might be considered culture by question three (“People often understand their problems in their own way, which may be similar or different from how doctors explain the problem. How would you describe your problem to someone else?”), it’s not until the seventh question that culture is explicitly mentioned: “Is there anything about your background, for example your culture, race, ethnicity, religion or geographical origin that is causing problems for you in your current life situation?”

The point of framing the questions this way  is to not make a big deal of culture while at the same time getting a good person-centered assessment that considers culture as important to how patients view their problems. This is meant to avoid the stereotyping that considering culture often leads to in situations in which clinician and patient differ on some cultural dimension. The CFI seems to provide space for individuals to define their problems as they see fit — i.e., to make explicit their own explanatory models — and then relate this to how others within their social networks (including family members and those that don’t share their culture) may see their problems.

My favorite exchange came after one audience member looked over the CFI and asked, “For whom would these questions not be relevant?”

Dr. Lewis-Fernandez replied: “Yes, exactly.”

The CFI is currently undergoing field trials. Read more about the proposed DSM-5 Cultural Formulation and the CFI, and express your opinion as to whether it should be emphasized (or not, I suppose), by following this link to the DSM-5 commentary website. Common sense needs advocates.

On a related note: If you haven’t read it yet, Allen Frances’ Op-Ed in Saturday’s New York Times, provocatively titled Diagnosing the DSM, is worth it. In it Dr. Frances, one of the architects of the DSM-IV, argues strongly that the DSM-5 development process should be untethered from professional psychiatry in order to build a better product. A teaser:

Until now, the American Psychiatric Association seemed the entity best equipped to monitor the diagnostic system. Unfortunately, this is no longer true. D.S.M.-5 promises to be a disaster — even after the changes approved this week, it will introduce many new and unproven diagnoses that will medicalize normality and result in a glut of unnecessary and harmful drug prescription. The association has been largely deaf to the widespread criticism of D.S.M.-5, stubbornly refusing to subject the proposals to independent scientific review.