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Mending Wounded Minds

Illustrations by Dung Hoang

Mending Wounded Minds (continued)

“In Zambia, we needed a model that was appropriate for 4- to 18-year-olds, we needed a model that included families, and we needed something that was fairly simple and teachable,” says Murray.

In TF-CBT, therapists help children to find connections between thoughts, feelings and behavior. A key component is “exposure”—helping the child begin to talk about the actual sexual abuse event. From there, they start to make connections between the abuse and their emotions and actions. The therapist might use drawing pictures or role-playing to help children construct their own abuse “narrative” through repeated retellings, a process intended to desensitize them to the abuse.

Murray assembled the 23 clinicians mainly through her contacts at Lusaka schools and NGOs in the area. The group includes psychology and child development students, as well as some local counselors who wanted some formal training. Murray also worked with a clinic at Lusaka’s University Teaching Hospital, which is designed primarily to provide medical treatment to sexually abused children. AMHR developed standardized intake and assessment forms that clinic staff now use as screening tools to identify the children most in need of TF-CBT services.

One of Jere’s clients is an 8-year-old girl who was sexually abused by a family member. “Generally, she’s a very jovial and very happy kid, but when I met her for the first time she seemed sad, quite withdrawn. She wasn’t playing with friends and didn’t talk very much,” says Jere. Her first step was to engage the child in some games and other activities that are part of TF-CBT, aimed at helping her to talk about the abuse.

“You get them to explain to you what the drawing is about,” Jere says. “For some we do role-playing, take them out of the situation. Another technique I use is asking them to talk about what happened as if it were a movie. It’s easier for them to look at things from the outside.”

Murray is in the process of training another cohort in TF-CBT, and using three clinicians from the original group of 23 to be on-the-ground supervisors of the therapy program. Longer term, she hopes to train the supervisors to do the training themselves, and expects to bring the AMHR-developed screening tools to other Lusaka organizations that work with children who have experienced trauma and/or grief.

“One of the most gratifying things to me is to watch my 23 counselors really become talented therapists, and to watch their successes and how they pick this up,” Murray says.

From Meager to Reliable Research

The AMHR team has spent the past decade slowly building its case—one project at a time—that it is possible to bring evidence-based mental health care to the developing world, even in the face of daunting obstacles: entrenched stigma, paltry funding and widespread shortages of qualified mental health practitioners.

The group is beginning to see a greater recognition from the public health community, local governments and international organizations of the long-neglected mental health needs of millions in low-resource countries. In October 2008, the WHO launched the Mental Health Gap Action Programme (mhGAP) to bridge the “huge treatment gap” that exists for mental, neurological and substance use disorders in the developing world. Defining mental health as a vital component of primary care, mhGAP urges governments and donors to boost funding and scale up treatment.

“This expanding interest means people are also looking for ways to investigate mental health, which is exactly what we do,” Bolton says. “In the past this was something we had to offer but nobody was interested.”

Increasingly, international aid organiza­tions that fund NGOs to provide mental health services are demanding proof that the care is actually helping people. “There’s been so much money wasted because there’s been so many bad programs,” Portman says, “and we just really want to do a good one.”

The AMHR-developed model of involving local populations in identifying mental health problems and interventions, and requiring evaluations of effectiveness, was built with sustainability and expansion as key goals. “We select interventions that are relatively low-cost, that don’t require high-level training,” Bass says, “so that the organizations we work with, whether it’s a ministry of health or an NGO, can actually continue to provide services should they prove to be effective.”

AMHR aims to leave its partners equipped with the public health tools they need to duplicate the group’s methods—from identifying problems, to setting up interventions and assessing impact—and in the process add another piece of reliable information to the meager body of work on mental health in the developing world.

“We want to have all these service providers constantly testing their interventions so that when you go to the lliterature there are studies saying what works,” Bolton notes. “The evidence is so thin and so rare ... . We see maybe two or three studies a year in developing countries that look at the impact of any mental health intervention. The only way we’re going to build an evidence base more quickly is if these providers are doing the research as part of their programs.”

“We’re people in a hurry,” Bolton says. “The mental health field is so behind; there’s so much to do.”

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