* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Download [read more]. - Aart of Life Foundation
Psychiatric rehabilitation wikipedia , lookup
Mental disorder wikipedia , lookup
Diagnostic and Statistical Manual of Mental Disorders wikipedia , lookup
Political abuse of psychiatry wikipedia , lookup
History of psychiatric institutions wikipedia , lookup
Victor Skumin wikipedia , lookup
Psychiatric and mental health nursing wikipedia , lookup
Classification of mental disorders wikipedia , lookup
Mentally ill people in United States jails and prisons wikipedia , lookup
Pyotr Gannushkin wikipedia , lookup
Abnormal psychology wikipedia , lookup
Causes of mental disorders wikipedia , lookup
Controversy surrounding psychiatry wikipedia , lookup
Deinstitutionalisation wikipedia , lookup
Mental health professional wikipedia , lookup
History of mental disorders wikipedia , lookup
History of psychiatry wikipedia , lookup
Grief and trauma counselling and psycho-social support : Perspectives in a changing society DAVID M. NDETEI MBChB (Nrb), DPM (London), MRCPsych. (UK), FRCPsych. (UK), MD (Nrb), DSc (Nrb), Certificate in Psychotherapy (London) Professor of Psychiatry, University of Nairobi (UoN) Founding Director, Africa Mental Health Foundation (AMHF) Faculty and Collaborator, The Chester M. Pierce, MD Division of Global Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston MA, USA Chair, African Division of the Royal College of Psychiatrists Zone 14 Representative, World Psychiatric Association Website: www.africamentalhealthfoundation.org Email: [email protected] / [email protected] PRESENTED DURING: THE AART OF LIFE INTERNATIONAL TRAUMA CONFERENCE AT THE UNITED STATES INTERNATIONAL UNIVERSITY NAIROBI, KENYA 26TH – 27TH AUGUST 2015 INTRODUCTION Human beings have lived with the threat of violence, injury and death throughout history. We expect therefore that there are mechanisms available to help us adapt to threats that do not destroy us. When threats are more severe and inescapable, other mechanisms come into play, including dissociation, and aggravated psychiatric conditions Problems linked to trauma are grief and other forms of reactive distress, depressive and anxiety disorders, and posttraumatic stress disorder (PTSD). How does trauma occur? It happened unexpectedly. You were unprepared for it. You felt powerless to prevent it. It happened repeatedly. Someone was intentionally cruel. It happened in childhood. Emotional and psychological trauma can be caused by singleblow, one-time events, such as divorce, a horrible accident, a natural disaster, rape, or a violent attack. Trauma can also stem from ongoing, relentless stress, such as living in a crime-ridden neighbourhood or struggling with cancer. Commonly overlooked causes of emotional and psychological trauma Falls or sports injuries Surgery (especially in the first 3 years of life) The sudden death of someone close A car accident The breakup of a significant relationship A humiliating or deeply disappointing experience The discovery of a life-threatening illness or disabling condition Risk factors that increase occurrence of trauma (Megan et al 2007) Group Increase occurrence Decrease occurrence 1 Medical personnel, disaster personnel, fire fighter, police men, military Long exposure during work hours Training improves resilience and self efficacy. 2 General population Lack of mental health care services Delayed reporting/ lack of awareness/ stigma/culture (association with spirits) Availability of mental health care services and policies, prompt reporting/increased awareness, treatment options 3 General population History of PTSD Improved Psycho-social support 4 General population Lack of social support Improved social support 5 Children (Pine and Cohen 2001) Level of exposure & psychopathology Improved Psycho-social support World statistics of trauma (WHO) No Country Group Percentage 1 United states Civilians 7-8 % 2 General War veterans 30% 3 United states High school students 3-6% 4 Pakistan Women refugees 86% 5 UK Female rape victims 45% 6 Cambodia civilians 3% 7 Across the world Refugees 10% 8 Mexico Earthquake victims 50% Trauma and violent conflict in Africa (contd.) Violent conflict, is perhaps one of the most widespread cause of enduring trauma on the continent In Kenya, my home country, we as a nation have been exposed to trauma as a result of violent conflict from the trauma of World War I and II where many Kenyans were conscripted to fight, one of them being my late father, witnessing and participating in the atrocities of war. Kenya’s struggle for independence – the Mau Mau war in the 1950’s also left its own enduring mark of trauma among the population. In 2005, about 45 years after the end of that war, a student of mine did a study on Mau Mau detention camp survivors, the veterans of that war, and found that a diagnosis of current Post Traumatic Stress Disorder (PTSD) was evident in 65.7% of the 181 survivors who participated in the study. Trauma and violent conflict in Africa After independence Kenya had other various incidences of armed conflict such as the Shifta war in North Eastern Kenya and the not too infrequent tribal clashes. Most recently, the threat of terrorism has constantly been at our doorstep. Since the 1998 bombing of the American Embassy and two years ago, the mass shooting at the Westgate Mall, not to mention the Garissa University attack. Unfortunately such events are not unique to Kenya alone, but can be seen in many other African countries and others around the world. Symptoms of trauma Emotional and psychological Shock, denial, or disbelief Anger, irritability, mood swings Guilt, shame, self-blame Feeling sad or hopeless Confusion, difficulty concentrating Anxiety and fear Withdrawing from others Feeling disconnected or numb Symptoms of trauma (Contd.) Physical Insomnia or nightmares Being startled easily Racing heartbeat Aches and pains Fatigue Difficulty concentrating Edginess and agitation Muscle tension TRAUMA RELATED WORK In my work, I have been involved in various efforts for trauma interventions following armed conflict and violence such as: The development and execution the Psychotrauma Programme (module) for the Rwanda Genocide (1995 - 1996) Development of a training programme for political refugees in Dadaab Camp in North Eastern Province Development of a training programme for counsellors following the terrorist bombing of the American Embassy in Nairobi in 1998 Training and providing counselling and psychiatric services to survivors of the 1998 bombing of the American Embassy, the 2007/08 postelection violence and even more recently, the students of Garissa University. AFRICA MENTAL HEALTH FOUNDATION (AMHF) Founded in 2004 to break away from silos of individual institutions (public and private) and different professions in order to bring them together under one roof. AMHF brings together the widest possible spectrum of professionals with something to contribute to mental health solutions and enhanced mental health wellbeing – These include: psychiatrists, clinical and counselling psychologists, social scientists, economists, human rights activists and people living with mental disorders all supported by a group of research staff experienced in research management, proposal writing, grant management, communication etc. TRAUMA RESEARCH BY AMHF AMHF has over the years conducted studies on trauma such as: The psychological effects of the Nairobi US embassy bomb blast on pregnant women and their children. A mental health needs assessment of Somali urban refugees in Eastleigh estate in Nairobi, Kenya. Traumatic grief in Kenyan bereaved parents following the Kyanguli School fire tragedy Traumatic experiences of Kenyan secondary school students TRAUMA: EVIDENCE FROM RESEARCH IN KENYA I will now take a few moments to share with you some of the findings of the studies we have done and what these results tell us about trauma interventions and what we should be looking to. As I have limited time, I will only give the overview of the conduct of the studies and the results. Detailed information and data is available through the various published papers. However, all proper scientific process and ethical considerations were followed in the conduct of each study. THE PSYCHOLOGICAL EFFECTS OF THE NAIROBI US EMBASSY BOMB BLAST ON PREGNANT WOMEN AND THEIR CHILDREN We carried out a descriptive study in pregnant women who were affected by the bomb blast occurring in Nairobi, Kenya on August 7, 1998 and their babies who were in utero at the time of the blast and contrasted the results to a control sample of similar pregnant women who had no history of trauma Both quantitative and qualitative data was collected using their medical records and a socio-demographic questionnaire, the Impact of Event Scale – Revised (IES-R) (6), the Childhood Personality Scale (CPS) (7) and Focus Group Discussions. THE PSYCHOLOGICAL EFFECTS OF THE NAIROBI US EMBASSY BOMB BLAST ON PREGNANT WOMEN AND THEIR CHILDREN (contd.) SIGNIFICANT RESULTS: The psychological effects of the disastrous event on exposed women, as assessed by the IES-R, were severe. There were significant improvements after three years in hyperarousal and reexperiencing subscales, but the average score on IES-R was still higher than 29 for the three subscales combined, suggesting that most of the study group was still suffering from clinical PTSD, although they reported they had found counseling helpful. The scores on all CPS subscales were significantly higher in children of the study group than in controls. Despite the perceived benefits of interventions limited effects on the intensity of PTSD were demonstrated in exposed mothers three years after the event, which emphasizes the need to evaluate psychological interventions for trauma victims with a view to making them more effective and culturally appropriate. A MENTAL HEALTH NEEDS ASSESSMENT OF SOMALI URBAN REFUGEES IN EASTLEIGH ESTATE IN NAIROBI, KENYA The purpose of this study was to highlight the prevalence of mental illness among Somali refugees in Nairobi and their ability to access mental health services. The tools used were the Mini International Neuropsychiatric Interview (MINI plus and MINI kid) which were translated into Somali language. A MENTAL HEALTH NEEDS ASSESSMENT OF SOMALI URBAN REFUGEES IN EASTLEIGH ESTATE IN NAIROBI, KENYA (contd.) SIGNIFICANT RESULTS: • PTSD was significantly associated with: • depression (p=0.001), • bipolar mood disorder (0.021), • OCD (0.012), • alcohol abuse (<0.001) and • khat use (p=0.004). This was a clear indication that PTSD can occur at the same time with other mental health and substance use conditions, therefore the need to identify and address them as well. This study was followed by another which provided brief intervention to to 315 somali refugees using Khat who were also diagnosed with PTSD. There was a 70% success rate in reduction of khat use among the study participants. TRAUMATIC GRIEF IN KENYAN BEREAVED PARENTS FOLLOWING THE KYANGULI SCHOOL FIRE TRAGEDY Following the death of 67 boys in a fire tragedy at Kyanguli School in rural Kenya, the level of traumatic grief was assessed in a sample of 164 parents and guardians whose sons died in the fire. The study was crosssectional. Counseling services were offered to all the bereaved parents soon after the tragedy. The subjects were interviewed using the Traumatic Grief Scale. A group of 92 parents/guardians was interviewed 2 months after the event, while the other group of 72 was assessed 7 days after the event. The second group of bereaved parents also completed the Self Rating Questionnaire (SRQ) and the Ndetei-Othieno-Kathuku scale (NOK). TRAUMATIC GRIEF IN KENYAN BEREAVED PARENTS FOLLOWING THE KYANGULI SCHOOL FIRE TRAGEDY (Contd.) SIGNIFICANT RESULTS: There was no much difference in terms of symptoms profile or intensity between the two groups. It appears that the counseling offered had minimal impact on the levels of distress. TRAUMATIC EXPERIENCES OF KENYAN SECONDARY SCHOOL STUDENTS The objective of this study was to describe the traumatic experiences of Kenyan high school students and to determine the levels of Posttraumatic Stress Disorder (PTSD) among them, and in relation to sociodemographic variables. The cross-sectional study was conducted among 1,110 students (629 males and 481 females), aged 12 to 26 years, Data was collected using self-administered questionnaires, the Trauma Checklist and the Child PTSD Checklist. TRAUMATIC EXPERIENCES OF KENYAN SECONDARY SCHOOL STUDENTS (contd.) SIGNIFICANT RESULTS: Being confronted with bad news was the most common type of trauma encountered in 66.7% of the subjects, followed by witnessing a violent crime and domestic violence; 23.2% and 16.5% of the subjects reported physical abuse and sexual abuse respectively. PTSD symptoms were common; Avoidance and re-experiencing occurred in 75% of the students and hyperarousal was reported by over 50%. The number of traumatic events was positively correlated with the occurrence of PTSD. The prevalence of full PTSD was 50.5%, while partial PTSD was 34.8%. Male and female subjects were equally affected but the boarders were more affected (p < 0.05) and the differences between the schools were statistically significant (p = 0.000). TRAUMA INTERVENTIONS: THE WAY FORWARD From these examples, it is abundantly clear that: THERE IS NEED FOR FURTHER RESEARCH AND INCREASED COLLABORATION BY VARIOUS DISCIPLINES TO PROVIDE APPROPRIATE AND EFFECTIVE EVIDENCE-BASED TRAUMA INTERVENTIONS However, there have been some advances in provision of effective interventions and I will now take some time to discuss some of these advances COMPREHENSIVE SUPPORT Effective interventions for trauma need to be comprehensive taking into consideration the following: Individual Family Friends Finances Culture Religion community COMPREHENSIVE SUPPORT (contd.): The Peter C. Alderman Foundation (PCAF) Psychotrauma Clinic PCAF partnered with AMHF to open a psychotrauma clinic in to offer psychosocial support to victims of the 2007/08 post-election violence in Kenya. The clinic is based in Nairobi near Kibera, one of the slums worst affected by the violence. Since it begun, the clinic has catered to 2400 clients, 70% of these being women who have suffered sexual abuse. The remaining 30% are men and children. In keeping with provision of comprehensive support, the clinic with funding from the African Women Development Fund (AWDF) has trained women attending the trauma clinic, in entrepreneurship and given them capital to start businesses for self sustainability. This project has ensured that patients with trauma are self reliant thus improving their overall health outcomes. CHANGING PERSPECTIVES OF TRAUMA COUNSELLING Through out history, trauma counselling has always focused on the individual, but it is now being realised that the complexity of influences reach far beyond the place where the event occurred. As a result, the effects go beyond family, community or country, to an extent, continent ad often the people left behind are equally affected. This is why we need to focus on: 1. Socio-cultural perspective: psychiatry has continued to see mental illness as a disease which recognizes symptoms regardless of culture in which they occur. Culture is now considered a variable which interacts with biology and environment to determine the cause of mental disorder. Behaviour is culturally related and all mental disorders and therapies should be culture specific. (Opler, 1959: Kiev,1964) CHANGING PERSPECTIVES OF TRAUMA COUNSELLING (CONTD.) 2. Psychological: which therapy work best in this community? 3. Financial: Doing way with the culture of dependence and ushering self reliance through social funds 4. Human rights perspectives: How do we make sure survivors tell their story and get Justice at the same time? CHALLENGES FACING SERVICE PROVISION IN TRAUMA INTERVENTIONS Psychiatrist to population ratio in many countries in Africa is still is low. Budgetary allocations for mental health services are less than 0.01% of the National Health budget in Kenya as in many similar countries. Training of mental health professionals takes time and resources that are not easily available. There are other compounding factors such as lack of financial resources because of poverty , lack of appropriate policies, lack of mental health awareness, competing priorities for health resources e.g. for HIV/AIDS and Malaria and lack of visionary leadership. Negative attitude and stigma towards Mental Health and patients Number of people involved in war or threats to war increase everyday Therefore, we must be innovative, mobilize and utilize the resources at our disposal through collaboration. MULTI-STAKEHOLDER APPROACH TO HARNESS RESOURCES FOR MENTAL HEALTH Stakeholders are multiple and include: 1. Mental Health Workers (Psychiatrists, counseling and clinical psychologists, nurses, psychiatric social workers) 2. Informal (lay) mental health workers – faith and traditional healers, community based workers, recovering patients 3. Other disciplines covering the full lifespan from conception to old age (Social scientists, health economists, Anthropologists, the media) MULTI-STAKEHOLDER APPROACH TO HARNESS RESOURCES FOR MENTAL HEALTH (CONTD.) 4. Other NGOs, Community based organizations, human rights groups and civil organizations 5. Communities and community leadership including administrative and political leadership 6. Policy Makers 7. Collaborators, partners and donors 8. Researchers to generate data to inform policy and practice 9. Above all people with mental illness and their families USING THE MULTI-STAKEHOLDER APPROACH TO HARNESS HUMAN RESOURCES FOR MENTAL HEALTH - TASK SHIFTING OF MENTAL HEALTH SKILLS The stakeholders in the formal health sector include: Nurses Clinical officers Community Health Extension Workers (CHEWs) – these are nurses trained on community outreach Community Health Workers(CHWs) – these are high school graduates identified by the communities in consultation with the Ministry of Health and trained by the Ministry of Health School counsellors 33 USING THE MULTI-STAKEHOLDER APPROACH TO HARNESS HUMAN RESOURCES FOR MENTAL HEALTH - TASK SHIFTING OF MENTAL HEALTH SKILLS (CONTD.) The stakeholders in the informal health sector include: Traditional Healers Faith Healers Expert Patients Self help groups Families 34 USING THE MULTI-STAKEHOLDER APPROACH TO HARNESS HUMAN RESOURCES FOR MENTAL HEALTH - TASK SHIFTING OF MENTAL HEALTH SKILLS (CONTD.) We at Africa Mental Health Foundation have had positive results using task-shifting and have even received further support from local county governments and other donors to scale up this innovative approach in the provision of mental health services. I urge all of us to consider this approach as well in trauma interventions. CONCLUSION It is possible to effectively address trauma through: Involvement of all stakeholders to address trauma comprehensively putting into consideration the individual, family, social relations, religion, culture and the community. Task shifting of mental health services through training of lay health workers to bride the gap in human resources available for mental health service provision. Integration of mental health services into primary healthcare facilities to make services available and accessible to the majority population. Research to come up appropriate and effective evidence-based community interventions. I wish to close my presentation with an invitation to all of you to attend this conference which provides a unique and exciting avenue for a multidisciplinary exchange of recent advances in trauma interventions and mental health on the African continent. You are all welcome. THANK YOU! FOR MORE DETAILS VISIT: www.africamentalhealthfoundation.org