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   Table of Contents - Current issue
Coverpage
January-June 2019
Volume 17 | Issue 1
Page Nos. 1-116

Online since Friday, June 28, 2019

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EDITORIAL  

From the editors: ringing the changes in 2019 p. 1
Wendy Ager, Marian Tankink
DOI:10.4103/INTV.INTV_12_19  
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ARTICLES Top

Collective trauma among displaced populations in Northern Iraq: A case study evaluating the therapeutic interventions of the Free Yezidi Foundation p. 3
Gail Womersley, Yesim Arikut-Treece
DOI:10.4103/INTV.INTV_56_18  
Yezidism arguably remains one of the most oppressed religions in Iraq, with the population historically confronted by many attempts at genocide. These atrocities have left many survivors displaced and affected by trauma, yet little research has been conducted on experiences of trauma among this population. In the context of an internal evaluation of the Free Yezidi Foundation’s mental health intervention in the Kurdistan Region of Iraq, 200 Yezidi women were screened at the beginning and end of a six-month mental health intervention using the World Health Organization (WHO)-5 well-being scale and the Harvard Trauma Questionnaire (HTQ). Qualitative data were obtained from sixteen focus group discussions (FGDs) among service users of the project as well as six in-depth qualitative interviews conducted with members of the project team. The results of the WHO-5 indicate a 74% increase in self-reported well-being among service users who completed the programme. According to the results of the HTQ, the baseline prevalence rate of posttraumatic stress disorder was 81.25%, which decreased to 45% upon completion of the programme. A qualitative analysis of interviews and FGDs highlighted that a significant impact on mental health were collective, multiple losses and separations (including family members who sought refuge abroad), the fact that not all Yezidi held in captivity have returned, fear of ongoing attacks and daily stressors related to poor living conditions. The results highlight the substantial impact of the political, legal and sociocultural environment on both the prevalence of trauma as well as processes of psychosocial rehabilitation. The implications for interventions include utilising socioecological frameworks for research and practice, engaging in advocacy and establishing agendas for mental health practice and psychosocial support that emphasises individual and collective self-determination.
Key implications for practice
  • Utilising eco-social frameworks for research and practice
  • Engaging in political advocacy as part of MHPSS interventions
  • Establishing agendas for mental health practice that emphasise individual and collective self-determination
  • Addressing the social, cultural and political perspectives of trauma as part of MHPSS interventions
  • Implementing interdisciplinary approaches to rehabilitation from trauma.
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Capturing the essential: Revising the mental health categories in UNHCR’s Refugee Health Information System p. 13
Peter Ventevogel, Grace K Ryan, Vincent Kahi, Jeremy C Kane
DOI:10.4103/INTV.INTV_66_18  
The Refugee Health Information System (RHIS) for humanitarian settings was developed by the United Nations High Commissioner for Refugees (UNHCR) in 2004. As of 2009, it contained seven categories related to mental, neurological and substance use (MNS) conditions: epilepsy/seizure, alcohol/substance use disorder, mental retardation/intellectual disability, psychotic disorder, severe emotional disorder, medically unexplained somatic complaint and other psychological complaint. During a recent overhaul of the RHIS, the MNS categories were revisited. This article describes the revision process and provides insights into how and why changes were made. Two rounds of consultations involving 34 expert reviewers in humanitarian mental health led to nine case definitions for MNS conditions in the new integrated RHIS (iRHIS): epilepsy/seizure, alcohol/substance use disorder; intellectual disability/developmental disorder; psychotic disorder (including mania); delirium/dementia; depression or other emotional disorder; other emotional complaint; medically unexplained somatic complaint; and self-harm/suicide. The use of additional specifiers enables dedicated mental health professionals in humanitarian settings to document a more refined diagnosis with a total of 22 different categories that made the system compatible with the modules of the Mental Health Gap Action Programme, without additional complexity.
Key implications for practice
  • The new iRHIS contains nine broad categories for MNS problems, reflecting consensus among humanitarian mental health practitioners.
  • iRHIS allows health workers in refugee settings to more accurately classify patients with MNS problems.
  • Specialized mental health workers in refugee settings can use additional specifiers in iRHIS to categorise their patients more precisely.
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Trauma Alleviation Treatment for unaccompanied children after the Rwandan Genocide: A cautionary tale p. 23
Sameera Shukanta Nayak, Sowmya Kshtriya, Richard Neugebauer
DOI:10.4103/INTV.INTV_10_18  
Tens of thousands of children were orphaned or separated from their parents by the 1994 Rwandan Genocide. Following an all too familiar practice in post-conflict societies, these children were placed in unaccompanied children’s centres (UCCs) referred to as orphanages. Staff in a proportion of these centres received training in simple trauma alleviation methods as part of a program instituted by United Nations Children’s Fund (UNICEF) with Rwandan governmental ministries. This study examines whether children in UCCs with staff trained in these methods had lower levels of post-traumatic stress symptoms (PTSS) than children in UCCs staffed by individuals without training. Data for these analyses derived from a National Trauma Survey conducted by UNICEF (1995) that included sampling of children from UCCs. Ordinary least squares multiple regression analysis was used to evaluate the effect of staff training on levels of PTSS among children, controlling for relevant covariates. Overall PTSS scores did not differ between children in UCCs with and without staff training. However, avoidance/numbing and hypervigilance symptoms were significantly elevated among females in UCCs with trained staff as compared with UCCs with untrained staff. Whereas these findings might result from unmeasured confounding variables, they nonetheless underscore the importance of formal assessment of treatment safety and effectiveness before implementing interventions.
Key implications for practice
  • Community-based approaches using a training of trainers approach may not always be effective when treating severe psychopathology after large scale violence
  • Humanitarian agencies must include rigorous monitoring and evaluation protocols as part of their intervention efforts
  • Mental health interventions should be adapted to address gender differences in child responses to interventions.
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Before my time? Addressing the intergenerational legacies of the genocide against the Tutsi in Rwanda p. 31
Veroni Eichelsheim, Lidewyde Berckmoes, Barbora Hola, Theoneste Rutayisire, Annemiek Richters
DOI:10.4103/1571-8883.239711  
This study aims to (i) understand how the legacies of the 1994 genocide against the Tutsi and its aftermath are transmitted to the next generation within Rwandan families and (ii) explore how institutional support plays a role in the pathways of intergenerational transmission. Through an in-depth analysis of qualitative interviews with 41 mothers and one of their adolescent children, we identified direct and indirect pathways through which the legacies of the genocide are transmitted to the second generation. Direct pathways concern the ways in which the genocide and its aftermath are reflected upon, reconstructed and explicitly communicated or silenced to the second generation. Indirect pathways are ways in which the genocide and its aftermath affect the life circumstances of the children, and through that, the child. Many of the included households had access to at least some kind of support. In general, our results indicate that organisations providing support to families and individuals in post-conflict settings might want to consider focusing explicitly on the identified pathways of intergenerational transmission to improve the living conditions of the next generation(s).
Key implications for practice
  • Development organisations that provide support to families in post-conflict settings could specifically address parenting, family relations and family communication and interactions to help participants secure a safe environment for the next generations to grow up in
  • Development organisations in post-conflict settings could specifically facilitate and encourage the interactions of participants with the broader social environment and the community to stimulate cooperation and social support
  • Stimulating the development of economic cooperation among the participants of support programmes in post-conflict settings as well as within their communities may be helpful in reducing intergenerational poverty.
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How to improve organisational staff support? Suggestions from humanitarian workers in South Sudan p. 40
Hannah Strohmeier, Willem F Scholte, Alastair Ager
DOI:10.4103/INTV.INTV_22_18  
Humanitarian workers experience high symptom burdens of common mental health problems. This requires action from the organisations they are employed with. However, many studies have documented continuing weaknesses in organisational staff support, as well as disparities in access to the services for national and international staff. Systematic data capturing suggestions from humanitarian workers on how to tackle this situation within a specific crisis setting is rarely available. This study addresses this gap through qualitative content analysis of the suggestions from the 210 humanitarian workers based in South Sudan collected through an online survey in 2017. Five major themes emerged regarding proposed improvements: ‘Competitive benefit and salary packages’; ‘internal work climate and organisational culture’; ‘equality within and between organisations’; ‘skill enhancement and personal development’ and ‘physical safety and security’. For both national and international staff, improved access to psychosocial support services was the most frequent proposal. Apart from this suggestion, their top priorities for improvement of staff support differed greatly. National staff emphasised improvements related to training and greater equality between employees. International staff emphasised improvements related to time off and team cohesion. Findings provide a clear case for organisations to assess their services and offer a potential framework to inform future interventions that better address the priorities of the humanitarian community as a whole.
Key implications for practice
  • Organisations need to ensure staff have adequate access to psychosocial support services
  • National and international staff have different priorities regarding staff support and organisations need to reflect these in their provision of services
  • A unified understanding of staff support is required to manage expectations of staff and hold organisations accountable.
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Humanitarian well-being: Addressing the intimate partner to promote humanitarian well-being, a literature review p. 50
Katie Spencer
DOI:10.4103/INTV.INTV_43_18  
Humanitarians are critical players in alleviating suffering worldwide. As a result of their willingness to put themselves in challenging, often dangerous environments, humanitarians are at high risk for negative mental health outcomes. Addressing humanitarian mental health effectively must consider the well-being of the intimate partner. The paper reviews the literature on humanitarian mental health, the protective nature of social support, the relevance of the intimate partner as a provider of social support, and outcome research on interventions that increase social support through the inclusion of the intimate partner. This paper draws comparisons between military and humanitarian intimate partners and provides information on the military’s research and programming as a model for humanitarian organisations to consider. One of the most effective ways to improve humanitarian mental health is to increase the well-being of the intimate partner and intimate relationship.
Key implications for practice
  • The humanitarian context can lead to high levels of poor mental health outcomes.
  • Humanitarian distress and attrition has a negative impact on an organization's mission effectiveness and bottom-line.
  • One of the most effective ways to improve humanitarian mental health is to increase the well-being of the intimate partner and intimate relationship.
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Project MIRACLE: Increasing empathy among psychosocial support staff working with refugees through brief training in motivational interviewing p. 59
Miriam Potocky, Kristen L Guskovict
DOI:10.4103/INTV.INTV_1_18  
Motivational interviewing (MI) is presented as a mental health and psychosocial support (MHPSS) approach for increasing empathy among psychosocial support staff working with refugees in resettlement. In a pilot study, 34 case managers in US refugee resettlement non-governmental organizations (NGOs) were trained in MI in a 3-h webinar format using a randomized controlled trial with a wait-list condition. Outcome was measured using the Helpful Responses to Refugees Questionnaire, which assesses empathetic responses to common refugee scenarios. Training group participants’ responses significantly improved from before to after training compared to the wait-list group which received no training; these results were subsequently replicated in the wait-list group after those participants received training. Pre–post effect sizes were medium to large. Participants reported that the training was useful and relevant, and that they applied the skills in their practice. Barriers and facilitators to use were reported. This pilot study had several limitations, including that the implementation of empathetic responses, their impact on the quality of the case manager–refugee relationship, and the ultimate impact on refugee outcomes could not be assessed. Implications for practice, NGO policy, future research and global MHPSS refugee programmes are discussed.
Key implications for practice
  • Brief MI training has demonstrated promise for enhancing empathy among psychosocial staff working with refugees
  • MI should be more broadly considered in MHPSS work in both emergency and non-emergency refugee settings
  • A webinar format is a cost-effective training approach that may be particularly relevant in conflict-affected areas globally.
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The case for—and challenges of—faith-sensitive psychosocial programming p. 69
Wendy Ager, Michael French, Atallah Fitzgibbon, Alastair Ager
DOI:10.4103/INTV.INTV_20_18  
Drawing upon evidence compiled in a recent literature review, we identify five arguments for seeking faith-sensitivity in psychosocial programming: it is indicated by the Inter-Agency Standing Committee (IASC) Guidelines on Mental Health and Psychosocial Support (MHPSS); it is implied by humanitarian law and principles; religion is an active and effective source of coping in many contexts; local faith actors have a ‘comparative advantage’ in humanitarian settings; and engaging with religion is coherent with emerging policy and practice. However, we also identify three major challenges in implementing faith-sensitive programming: religion may be used as a basis for maladaptive coping; religious engagement is considered a threat to impartiality; and practices of engaging with religion are poorly documented, disseminated and developed. This suggests the value of guidance on faith-sensitive psychosocial programming—consistent with the existing IASC MHPSS guidelines—suitable for implementation by both faith-based and non-faith-based actors.
Key implications for practice
  • The role of faith in supporting well-being and recovery and the importance of engaging with local capacities and institutions both point to the relevance of faith-sensitive psychosocial programming.
  • Humanitarian law and principles promote respect for religious practice and freedom of religion.
  • Humanitarian agencies are potentially discouraged from engaging with religion by concerns about partiality, proselytism and the potential for religion to ferment conflict.
  • There is a need to develop, document and disseminate appropriate faith-sensitive programming practices more effectively.
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Geographies of adolescent distress: A need for a community-based psychosocial care system in Nepal p. 76
Nawaraj Upadhaya, Carola Tize, Ramesh P Adhikari, Dristy Gurung, Ruja Pokhrel, Sujen M Maharjan, Ria Reis
DOI:10.4103/INTV.INTV_21_18  
This paper presents the findings of an ethnographic study conducted among high school students in Nepal. Participant observations, in-depth interviews and focused group discussions were conducted among 35 students (20 girls and 15 boys). The findings suggest three geographies (home, school and community), where adolescents experience distress. Common experiences of adolescent distress included discrimination, domestic violence, heavy workload, poverty, bullying, physical punishment, unsupportive behaviour of the parents and teachers and a lack of basic materials. These findings largely support Bronfenbrenner’s socio-ecological model, emphasising the complex reciprocal interactions between the individual and his/her immediate environment. They also suggest that not only a reciprocal relationship between the sub-systems of the ecological model, but also a ‘mobility’ between and among these sub-systems affects the individual’s emotional-relational well-being. We argue that the micro-systems in which children grow up not only have a social dimension, but a spatial dimension as well. Building on this insight, a five building-block intervention model is presented to help address adolescent distress.
Key implications for practice
  • Given adolescents' mobility between home, school and community, a community-based psychosocial care system is proposed that also addresses distress related to the in-between travelling spaces.
  • Such a system would comprise family support, peer-to-peer education, community mobilisation and school mental health.
  • School counsellors should provide counselling in the school, but also use home visits and in-between travelling spaces as implementation sites for interventions.
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The impact of psychosocial support on well-being and agency within an inclusive livelihood programme p. 86
Davide Ziveri, Shirin Kiani, Melanie Broquet
DOI:10.4103/INTV.INTV_26_18  
After 7 years of a multifaceted conflict, effective humanitarian assistance for people living in Syria is vital. This action research explores the extent to which psychosocial support (PSS) impacts the well-being and agency of Syrian farmers benefitting from livelihood. Our methodology used a baseline and endline survey towards a target population of households receiving agricultural inputs, with both an experimental and control group. Five dimensions of well-being were considered: emotional, social, economic, skills and knowledge and overall feeling. The key findings are:
  • A stand-alone livelihood programme does in fact have a positive impact on psychosocial well-being;
  • An integrated PSS and livelihood programme, as expected, has a positive impact on psychosocial well-being;
  • There is larger comparative impact of an integrated PSS-livelihood programme compared to a stand-alone livelihood programme for beneficiaries;
  • We learned that compared to those without disabilities, beneficiaries with disabilities experienced a larger benefit from PSS.
These results strongly suggest that an integrated approach providing PSS alongside livelihood interventions has added-value for vulnerable persons to restore their resilience. The results of this pilot study would need to be confirmed by a larger scale study to validate the findings.
Key implications for practice
  • Measure of the impact of psychosocial interventions in conflict settings.
  • New model of livelihood programme.
  • Focus on people with disabilities in armed conflicts.
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FIELD REPORTS Top

Higher education and forced migration: An evaluation of psychosocial support provided for Syrian refugees and the Jordanian host community p. 96
Amina M Steinhilber
DOI:10.4103/INTV.INTV_53_18  
Access to higher education as well as obtaining an academic degree is burdensome for Syrian refugees and socially disadvantaged Jordanians. The two social groups also show an increased vulnerability to mental disorders. The present study evaluates if the provided psychosocial support is socially and emotionally helpful for 75 students (35 Syrian refugees; 40 socially disadvantaged Jordanians) in a scholarship programme for Masters studies in Jordan. Both social groups were expected to report vulnerability to depression and anxiety. Females were assumed to be more vulnerable. Psychosocial support measures were presumed to be evaluated positively. Females were expected to evaluate academic support more positively than males, whereas Syrians were anticipated to perceive the social support more positively than Jordanians. A total of 21 Syrian and 22 Jordanian scholarship holders filled out a questionnaire for assessing their levels of depression and anxiety, ratings of the provided psychosocial support measures and perceived social support by staff of the scholarship programme. Quantitative data analysis confirmed the provided psychosocial support to be helpful. Psychosocial support is socially and emotionally helpful for Masters students of the given groups. Differences in gender and nationality should be considered, when designing psychosocial support measures.
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Psychological first aid for children during the Kumamoto earthquake disaster response in Japan p. 103
Miyuki Akasaka, Yuzuru Kawashima
DOI:10.4103/INTV.INTV_3_18  
The following field report is based on lessons learned from the adaptation and utilisation of the Psychological First Aid for Child Practitioners (Save the Children, 2013) materials in Japan. Psychological first aid (PFA) is a set of skills and competencies that help reduce the initial distress of children and caregivers due to accidents, natural disasters, conflicts or other critical incidents. The manual was developed by Save the Children based on Psychological First Aid: A Guide for Field Workers (World Health Organization, War Trauma Foundation and World Vision International, 2011). National capacity-building in PFA was focused in Japan on mental health professionals and emergency responders to enhance mental health and psyschosocial support in times of disaster. In April 2016, during the Kumamoto earthquake, emergency disaster responders in Japan learned PFA and worked at child friendly spaces for children and caregivers.
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PERSONAL REFLECTIONS Top

Early discontinuation of counselling by survivors of family violence in Papua New Guinea p. 109
Paulina Acosta
DOI:10.4103/INTV.INTV_65_18  
Family and sexual violence are common and widespread in Papua New Guinea, especially against women. The author describes her reflections about reviewing the psychosocial support mode of intervention according to the needs of survivors of family violence at the Family Support Centre within Tari Hospital in the southern highlands of the Hela Province, while working as a psychologist supervisor from 2011 to 2012. It draws on a feedback exercise with survivors, intended to ask about their satisfaction with services and the reasons for not returning for follow-up counselling sessions. The answers provided valuable insights for the adjustment of care in a culturally appropriate manner to survivors’ needs.
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IN MEMORIAM Top

Shaping policy and practice: Mental health and psychosocial work – the legacy of Dr. Barbara Harrell-Bond p. 114
Maryanne Loughry
DOI:10.4103/INTV.INTV_7_19  
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ERRATUM Top

Erratum: Witnessing the vulnerabilities and capabilities of one Afghan woman: Cultural values as a source of resilience in daily life p. 116

DOI:10.4103/1571-8883.261739  
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