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Mending Wounded Minds

Illustrations by Dung Hoang

Mending Wounded Minds (continued)

According to the WHO, more than 75 percent of people with mental disorders in developing countries receive no treatment or care. Globally, depression affects approximately 154 million people. WHO’s World Health Report 2001 ranks depression as one of the top five disabling conditions. Mental illness varies in terms of age of onset and without treatment can last a lifetime.

The public health consequences of ignoring mental illness in the developing world are great, notes Bolton. Studies have shown that depression is a risk factor for heart disease, cancer and alcohol abuse. Research in Pakistan found that children born to depressed mothers have lower birth weights, which increases the risk of death from diarrheal disease. Other research has found that depression speeds the progression of HIV and more than doubles the mortality rate in HIV-positive women.

In the arena of international mental health, AMHR is one of only a few research groups working in collaboration with service providers to bring scientifically proven, cost-effective mental health services to those most in need. Central to the AMHR model is a commitment to view mental health through a local lens. That means using ethnographic study methods to talk with local populations to understand their mental health problems from the perspective of their own culture. This is the foundation for AMHR’s subsequent scientific work of selecting and adapting interventions in ways local people will understand and accept. AHMR then collaborates with the providers to conduct scientific studies, such as controlled trials, to assess how effective the services are.  

Too often, says Bass, NGOs and other service providers bypass the local perspective and simply import Western-based assessments and therapies that may not translate well to other cultures. “We need to know what the problems are, and we first spend time doing needs assessments,” she says. “We don’t go into a place and say, ‘Oh, there’s a disaster; everybody must have PTSD [post-traumatic stress disorder].’ We take an exploratory approach and determine what the problems are and how they affect people’s functioning and daily lives.”

In a poor Zambian community ravaged by HIV, Laura Murray wanted to learn about the women and children’s mental health. Local interviewers found that 40 percent of the women reported child sexual abuse as a problem. She’s leading a therapy project to reduce the trauma.

Healing Damaged Psyches

Through his work with AMHR, Paul Bolton knows how living as a refugee, surviving a natural disaster, torture or a war can damage the psyche. Still, the stories of torture survivors in Kurdistan revealed a degree of brutality he had not encountered before.

“We work with torture-affected populations in different countries, and the common story is somebody is taken from their home then taken to a place where they’re tortured, and either killed or eventually released,” Bolton says. “It was different in North Iraq. People would be arrested, taken to a place and tortured, but the victim’s family would periodically be brought to the prison and forced to watch the torture, the girls might be raped and then the family would be sent home.

“We’ve heard many stories, and these are the worst I’ve ever heard,” Bolton says. “This was torture at a different level, very much both mental and physical torture.”

AMHR is now collaborating with Heartland Alliance (HA), a Chicago-based NGO that in 2004 introduced limited mental health services to its network of primary care health clinics, mainly in the Kurdistan region. The goal: help the large number of torture survivors in the area cope with PTSD, depression and anxiety.

Mental health professionals in Iraq are in extremely short supply, so mental health care in the clinics is typically provided by medical assistants with minimal training in psychological disorders. “We’re hoping to come up with one or more interventions that can be taught easily to paraprofessionals and that are cost effective,” says Scott Portman, HA’s director of international programs. He connected with AMHR through the USAID’s Victims of Torture Fund. “We also want it to be easier for people who suffer from disabling traumatic stress or depression to access services,” he adds.

AMHR’s first step in Kurdistan—as it is in whatever area is under study—was to find out what mental health problems exist, from the perspective of the affected population. AMHR-trained local interviewers asked open-ended questions of residents and used ethnographic methods to tease out a list of general problems, including mental problems. With HA, the AMHR team put together a screening tool/questionnaire to identify the mental health problems among local people and assess their severity.

“Using the ethnographic data we try to design an intervention that makes sense to people, is consistent with how they might address a problem,” Bolton explains. The last part of the process is to run a controlled trial to assess the intervention’s impact.

The Kurdistan assessments found depression, anxiety, PTSD and traumatic grief—which results from the loss of someone under sudden and/or violent circumstances—to be the most common problems among torture survivors. “What we have done since then is reach out to torture experts around the world and say, ‘What can we do for this population that’s locally feasible, known to be effective and deals with these particular problems,” Bolton says. “And in the case of Kurdistan, we’ve come up with two interventions that we’re planning to test”—behavioral activation and cognitive processing therapy. 

Behavioral activation is designed to treat depression and is based on the simple premise that an individual’s mental state will improve if they engage in activities that make them happy. During the 12-week course of treatment, locally trained mental health counselors will work one-on-one with patients to help them identify and participate in activities that they find pleasurable.

“It’s so simple, and frankly simple is what we need,” Bolton says. “It is easy to train local people to provide the intervention, and it’s cheap to implement.”

The theory behind cognitive processing therapy is that sufferers of depression, anxiety, and PTSD mainly exhibit their distress by avoiding anything that reminds them of the original trauma. Eventually avoidance comes to dominate their lives. For someone who was tortured by an Iraqi soldier, seeing a police officer may trigger memories that escalate to the point where the sight of anyone in a uniform unleashes a storm of disturbing thoughts and an anxiety attack.

In Kurdistan, counselors work to gradually draw patients out to talk about the trauma, and through reducing the avoidance behavior, to begin to look more objectively at their emotional responses. The idea is to guide patients toward a more realistic understanding of the event, Bolton says. For example, “That happened because Saddam was in charge, and it’s not going to happen again. I didn’t prevent my wife from getting raped because it was absolutely impossible for me to do it.”

Recently, Bass and four U.S.-based clinical psychologists traveled to Sulaiymaniya to train two groups of community mental health workers (CMHWs) in the interventions. Working together, the trainers and the CMHWs adapted the Western-based therapies to align with the culture and mental health needs of the Kurdish population. The community health workers are now providing the therapies as part of their regular services to clients. Bolton and Bass are scheduled to return to the area to set up the research component of the program to evaluate the effectiveness of the therapies in reducing depression and distress in the population.

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