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Mending Wounded Minds

In developing countries, three-quarters of people with mental disorders receive no treatment. How do you deliver inexpensive, effective, science-based care to them? A team of mental health researchers has a few ideas.

By Jackie Powder

The Kurdish people of northern Iraq have endured the worst that man can do to man. Operation Anfal, Saddam Hussein’s campaign of genocide against the Kurds, claimed 180,000 victims—5,000 killed in the poison gas attacks of 1988—and destroyed thousands of villages, forcing residents from their homes to refugee camps on the Turkish border. During this wave of terror, males were routinely detained, taken to military facilities, interrogated, tortured and often executed. In some cases, their families were forced to watch the killings in a public place, applaud and then pay for the bullets used in firing squad assassinations.

More than 20 years have passed, and Saddam Hussein is gone. What remains is a damaged population—torture survivors, their relatives and the families of the dead—that continues to live with crippling psychological pain.

“It’s very common to find families having one or two members who have been jailed or tortured,” says Ahmed M. Amin, MD, medical director of a trauma recovery and training center in Sulaimaniya. “For example, if I am not jailed, my brother was jailed; if not my brother, my sister or my cousins.

“We know that they are in grave need of mental health support services,” Ahmed says. “They have a great burden on their shoulders, and they are suffering on a daily basis.”

To ease the debilitating mental pain that frequently destroys family relationships and impedes day-to-day functioning, the Bloomberg School’s Applied Mental Health Research (AMHR) group is working on a project to help torture victims in Kurdistan. The effort is led by Paul Bolton, MBBS, MPH, an associate scientist in International Health, and is supported by USAID’s Victims of Torture Fund.

The AMHR group is dedicated to implementing and testing evidence-based mental health services in developing countries where care for the mentally ill is frequently non-existent or ineffective. Bolton and colleagues Judith Bass, PhD, MPH, and Laura Murray, PhD, assistant professors in Mental Health and International Health, respectively, comprise the core of AMHR, which they founded at Boston University’s School of Public Health in 2004.

The group has worked with street kids in Georgia, Albania and Mexico, sexually abused children in Zambia, Indonesian villagers caught for two decades in the crossfire of warring political factions, and with affected populations in Uganda, Cambodia and Haiti.

AMHR doesn’t provide treatment services directly, but rather fills a void in how these services are planned, executed, and provided. The group uses data collection methods in collaboration with service providers to identify major mental health problems, assist in the selection and design of mental health interventions to address these problems, and set up monitoring and evaluation methods to assess their impact. It is then up to the service providers—typically NGOs or ministries of health—to deliver the selected science-based mental health care.

“I would say that international mental health at the moment is certainly not a science-based or evidence-based field, leaving people free to do whatever they think is a good idea at the time,” says Bolton, who originally trained as a family physician in Australia. In the late 1980s, he focused on tropical medicine, treating malaria, tuberculosis, parasitic infections and diarrheal diseases among refugees in camps along the Thai/Cambodian border. In 1996, he joined the Child Survival Support Program at Johns Hopkins.

“I saw people with mental illness,” Bolton says, “but we had nothing to offer them.” He adds, “The contrast between the rigorous evidence that underlies physical health programs, and the poor basis for the few mental health services that were being provided was really marked.”

While mental health issues in the developing world have not drawn wide attention, they disrupt the lives of millions, says Bolton. The effects of mental illness can ripple wide, far beyond an individual’s personal pain and dysfunction to economic hardship and the disintegration of families.

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.”

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.

Stopping the Snowball

The topic of child sexual abuse is almost too painful to acknowledge, whether in the industrialized West or in sub-Saharan Africa’s poorest countries. In the past few years, however, health officials in Zambia have begun to confront the issue through awareness campaigns and specialized medical services—in part because of the high prevalence of HIV among young girls, the most frequent victims of sexual predators. Especially vulnerable are AIDS orphans who have lost both parents and must live with relatives or neighbors, some of whom become their abusers.

AMHR’s Laura Murray is overseeing a project in Zambia to introduce mental health care to sexually abused children. The goals are twofold: to ease the immediate effects of trauma, and to head off potentially irreversible damage that could manifest itself in adulthood as substance abuse, risky sexual behavior or mental illness.

“If you don’t treat child sexual abuse, the research tells us it’ll snowball into a lot of adult mental health issues,” says Murray, who, as part of a feasibility study, trained 23 local clinicians in an evidence-based therapy with a strong record of success in treating sexually abused children.

For the past nine months, the clinicians have been providing the therapy to sexually abused children ages 4 to 18 throughout Lusaka. Prior to AMHR’s involvement, no effective therapy was available in Zambia for young victims of sexual abuse. “The therapists are actually meeting with children and parents all over the city: under a tree, at a church, in a house, a school,” says Murray.

Jackie Jere, a counselor in Zambia with a background in educational psychology who has worked with the United Nations High Commission for Refugees, jumped at the chance to train with Murray. “We lack manpower in the field of therapy,” she says. “This was an opportunity for me to gain the skills to become a professional therapist so we can adequately help people who need treatments.”

Jere has found that many individuals who identify themselves as counselors in Zambia, as well as in other developing countries, are not properly trained. “There’s a lot of counseling going on, regardless of the level of qualifications you have,” she says. “A lot of children receive counseling that I think is ineffective.”

The pilot study in Zambia grew out of Murray’s efforts to learn about the mental health concerns of women and children living in a low-income compound outside of Lusaka with a high HIV prevalence rate.

A review of data collected by AMHR-trained local interviewers, who spoke with the women and children, identified a need for mental health services geared to treat child sexual abuse. Forty percent of the women and 30 percent of the children themselves reported “defilement,” or sexual abuse of children, as a problem. The survey also found that 52 percent of women said that orphaned children were seen as second-class citizens by their adopted families.

After reviewing various options for treatment, AMHR settled on Trauma-Focused Cognitive Behavioral Therapy (TF-CBT). The approach has been effective in treating trauma stemming from child sexual abuse, grief, disaster and other causes.

“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.”