I ‘stumbled’ on this great blogpost by Andrew Rasmussen on the annual meeting of the ISTSS. Andrew is an associate professor of Psychology at Fordham University and has served as a deputy for the conference. He has been so kind to let me cross-post his thoughts. The original, slightly more extended version can be found on his blog, where he writes about psychology, culture, and displaced populations.
The annual meeting of the International Society for Traumatic Stress Studies (ISTSS), this year held in Los Angeles, wrapped up November 3rd. This year’s theme, Beyond Boundaries: Innovations to Expand Services and Tailor Traumatic Stress Treatments, was in large part a response to a lack of global and cross-cultural perspectives at most ISTSS meetings.
This year the planning was directed by two global mental health researchers, Debra Kaysen and Wietse Tol, and global perspectives were given the main stage. This was most obvious in two of the keynote addresses, one by global mental health luminary Vikram Patel and longtime transcultural psychosocialist Joop de Jong.
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 its own symposium. Theresa Betancourt 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, 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 (i.e. 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 classroom training (a few days) 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 country’s national health strategy. 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, 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.