Mental Health Services for Survivors of Mass Violence

Nearly one sixth of the world's population has experienced mass violence, be it abducted Ugandan children who are forced to commit atrocities against their families and serve as child soldiers or Iraqi civilians who daily live with bomb blasts, killings, and sectarian violence.

More than 1 billion persons today have been affected by the experience of war, ethnic conflict, torture, and terrorism, according to Richard Mollica, MD, MAR, director of the Harvard Program in Refugee Trauma (HPRT). Created in 1981 and administered by Massachusetts General Hospital, HPRT has since then cared for more than 10,000 survivors of mass violence and torture.

"Some 25 years ago we were not optimistic that people who had been through extreme violence or torture could recover. Twenty-five years later, the answer is yes, they can and they do," Mollica said, adding that the most up-to-date thinking on approaches to diagnosis and treatment are described in his recent book, Healing Invisible Wounds: Paths to Hope and Recovery in a Violent World(Harcourt, 2006).

Project 1 Billion
To assist survivors of mass violence on a global scale, Mollica, who is also professor of psychiatry at Harvard Medical School, worked with health representatives from a number of affected countries with the goal of producing a science-based, culturally adaptable, and sustainable plan to serve the mental health needs of traumatized populations. The group met in Rome in 2004 and endorsed the Project 1 Billion Mental Health Action Plan (accessible at: http://www.hno.harvard.edu/press/pressdoc/supplements/mentalhealth.pdf) and the science-based Book of Best Practices, to be published by Vanderbilt University Press this year.

Part of this effort was to create a training program to develop a network of global leaders in mental health recovery. The program includes on-site learning in Italy with international experts followed by 5 months of Web-based learning in the students' home countries. Educational and service efforts work with local primary health care systems, traditional healers, and national and international nongovernmental organizations (NGOs). One of the NGOs that has been providing significant support is the Peter C. Alderman Foundation.

Alderman Foundation
The foundation was started by Elizabeth Alderman and Stephen Alderman, MD, after their 25-year-old son, Peter, was killed on September 11, 2001, while attending a technology conference at the World Trade Center.

"We felt we needed to do something to honor Peter's memory, but we really didn't have a clue," said Liz Alderman. "One night I happened to catch a Nightline broadcast about walking wounded victims of terrorism and violence around the globe. It featured Dr Richard Mollica and the [HPRT], and I felt this was the perfect thing for us to become involved in. Peter was killed because of terrorism, and if we could do something to help the people who survived the events but were still unable to live their lives because of their emotional wounds, this would be the perfect memorial for him." They contacted Mollica and 10 days later they met with him.

"I asked the Aldermans if they would fund a master class to train people from postconflict and conflict countries," said Mollica.

To support Mollica's vision, the New York couple formed the Peter C. Alderman Foundation, endowing it with $1.6 million from compensation funds given to 9/11 families, Peter's estate, and their own money.

Master classes train leaders
The first master class to train global leaders in mental health recovery was held in 2003, and 3 have followed. Participants, mostly primary care physicians, come from countries such as Bosnia, Iraq, Afghanistan, Cambodia, Chile, Uganda, and Indonesia. They spend a week in Ovieto, Italy, where they brainstorm about their field experiences, receive training from trauma psychiatry experts, and are supplied with a comprehensive package of training materials called the "toolkit."

The toolkit, developed by HPRT after September 11, includes 11 steps for clinical care of trauma survivors; 2 standard assessment instruments used in the United States (the Hopkins Symptom Checklist 25 and the Harvard Trauma Questionnaire); and discussions of scientific issues and psychotropic drugs for victims of trauma.

 

The value of the class was endorsed by one former participant. The HPRT toolkit "was very useful and has formed the basis of a... manual that we have developed to train health workers in Uganda working in conflict situations," said Eugene Kinyanda, MD, consultant psychiatrist at the Butabika National Psychiatric Referral and Teaching Hospital in Kampala. During the class, Mollica also gave Kinyanda professional advice as he prepared "to undertake the biggest study to date on mental health in my country."

In much of the postindependence history of Uganda, the country has experienced nearly continuous warfare, armed insurgencies, political instability, population displacements, and family disruptions.

"Until recently it was dangerous, since one could easily be caught up in the conflict and be injured or killed," Kinyanda said. "The [associated] psychological problems are many, the trained therapists are few, and there is too little funding to this area."

Another master class participant, Nesif Al-Hemiary, MD, lecturer in psychiatry and consultant psychiatrist at the University of Sulaimani College of Medicine in Iraq, found the lectures about management of psychological trauma through counseling and psychotherapy particularly helpful.

The classes also "gave me a vision about how to proceed in this field and the impetus to participate in translating the Harvard Trauma Questionnaire into Arabic and Kurdish versions," he said.

So far, 35 doctors from 12 countries have been trained in 4 master classes, according to Steve Alderman. They, in turn, have trained a cohort of 300 people, including psychiatric social workers, psychiatric nurses, teachers, and village leaders.

The upcoming master class, which will invite previous participants, will focus on supervision and support of clinical teams in various countries.

Classes to clinics
The Alderman family, including their adult children, have become personally involved in global mental health services through their foundation. With Mollica, the HPRT staff, and other experts, Liz and Steve Alderman contribute to the master class series.

"We attend them, and afterwards we sit and do a recap of what needs to be changed and improved. During all of this, we make wonderful relationships with these healers," declared Liz Alderman.

On the strength of those relationships, the Aldermans decided to support the creation of clinics in affected countries. Each foundation-sponsored clinic is directed or supervised by master class trainees and exclusively engages local, indigenous caregivers. Each clinic also seeks to partner with local governments, medical schools, and religious institutions.

In March 2005, the HPRT introduced the Alderman Foundation to a clinic HPRT had started in 1994 in Siem Reap, Cambodia. The Cambodian government provided the clinic with space on the grounds of a large hospital, some psychotropic drugs, and some of the consumable supplies. When Steve Alderman visited Cambodia, he arranged for the foundation to provide long-term funding for the clinic and its staff.

Among the special features of the Cambodian clinic are its focus on home visits and its relationship with local Buddhist monasteries. For example, once the patients are discharged from the clinic, the monks maintain a relationship with the former patients to help with any problems and to monitor recidivism. In the first year of operation, the Cambodian clinic had 4000 patient visits and 400 home visits and a 14-month waiting list developed. The Aldermans then opened a second clinic in the country.

In Uganda, the foundation recently opened a clinic in Tororo (eastern Uganda) as an outreach program. It is the first of 3 planned clinics in the country. Additional clinics are planned to be opened over the next several years in Rwanda, Burundi, and western Kenya.