International Mental Health Policy: the Nicaragua precedent

by Eva Shaw, PBB Intern

As awareness and knowledge continues to grow regarding the global burden of disease attributable to mental health problems, researchers, communities, agencies and governments search for large scale solutions that promote improved quality of life, especially for populations impacted by war and disasters. Models include microcredit provision, promoting community social support and self-efficacy, or the training and implementation of integrated care programs within existing health systems. Part of that search involves understanding how the world of health policy interfaces with international mental health efforts. PBB is likewise interested in mental health policy, recently adding “Policy Development” pages to their website.

In the spirit of inquiry, I offer the following case as an example to consider how international treaties can serve as tools to protect the health of peoples around the world.

While I was a student of public health policy and management at the University of Arizona, Tucson during 2005-2006, I planned a lecture series for students and faculty interested in international health. As part of the series, and due to my own curiosity in international health policy, I invited a student of Professor James Anaya and the Indigenous People’s Law and Policy Program to speak to the group at my home.

Professor Anaya is a renowned lawyer whose work aims to protect the land and rights of indigenous peoples around the world; he was appointed in 2008 to serve as the United National Special Rapporteur on the Situation of Human Rights and Fundamental Freedoms of Indigenous Peoples. During the presentation given by his student Leonardo Alvarado, now an assistant professor of indigenous studies at Northern Arizona University, we learned of the Awas Tingni versus Nicaragua case. In their article, “The Protection of Indigenous Peoples’ Rights over Lands and Natural Resources under the Inter-American Human Rights System” professors Anaya and Willams (2001) discuss how the promulgation of treaties since the International Labour Convention No. 107 of 1957 leading up to the Declaration of the Rights of Indigenous Peoples, along with the indigenous peoples’ rights movement, created standards and discourse which today influence other U.N. committees and processes. Such bodies are the U.N. Committee for Human Rights, the U.N. Committee for the Elimination of Racial Discrimination, as well as the World Bank, the Inter-development Bank and domestic legal agencies working for indigenous peoples’ rights. These developments “reflect the ever increasing interdependencies, ever improving communication technologies and burgeoning international institutions that characterize the contemporary international system and its human rights regime…” (p. 35.) The United Nations Committee on Human Rights as well as the Organization of American States (OAS) Inter-American Commission on Human Rights (which serves to protect indigenous peoples’ rights in Latin America) have taken numerous complaints and investigated cases on behalf of indigenous peoples. The Awas Tingni case was the first case that the OAS actually prosecuted,  to protect  the Nicaraguan Mayagna and Miskito indigenous groups’ rights to their land despite logging claims by the Nicaraguan government (and a contracted Korean corporation). Because the Nicaraguan government had during a previous administration become party to the American Convention on Human Rights, it was determined that the disputing administration was still required to abide by its tenets. Significantly, following the ruling, for the first time the World Bank conditioned delivery of an aid package on the outcome of the case, specifically for the Nicaragua government to develop a plan demarcating the lands belonging to the Mayagna and Miskito tribes in order to receive their aid.

After the presentation, the group at my home discussed whether the Nicaragua ruling could serve as a template to protect international health. Could, for example, United Nations or regional courts take complaints from human rights bodies or community representatives regarding health-related violations of the U.N. Convention on the Rights of a Child, to which 193 countries are party (not including the United States)?  Or, could complaints be submitted to protect the health of women according to the Convention on the Elimination of All Forms of Discrimination against Women, signed by 186 countries (and signed but not ratified by the United States)?  How about the Convention on the Rights of Persons with Disabilities (68 parties, signed but not ratified by the U.S.)? Or, the International Covenant on Economic, Social and Cultural Rights (160 parties, signed but not ratified by the U.S.), including Article 12 which states, “the States Parties to the present Covenant recognize the right of everyone to the enjoyment of the highest attainable standard of physical and mental health”? Could it be possible that through the organization of appropriate legal bodies, governments could be held accountable to support the mental health of peoples around the world? The Awas Tingni case is a remarkable advancement regarding the use of international treaties to protect indigenous peoples’ well-being. One wonders if there will be a time when other rights, such as health and mental health will be protected via international law and policy, as well.

For more information, see:

International Human Rights Instruments

http://www2.ohchr.org/english/law/

The United Nations Treaty Collection: Treaty reference guide http://untreaty.un.org/English/guide.pdf

Anaya, J. & Williams, R.A. (2001). The Protection of Indigenous Peoples’ Rights Over Lands and Natural Resources Under the Inter-American Human Rights System, The Harvard Journal of Human Rights, (14) 33.

The University of Arizona Indigenous Peoples’ Law and Policy Program http://www.law.arizona.edu/depts/iplp/index.cfm

Eva Shaw, MPH is a PBB intern and a graduate student of clinical social work at University of Texas, Austin.

Former nurse’s aide in US becomes Ugandan king

Story taken from Yahoo News.

AP – Charles Wesley Mumbere during an interview at his house in Kasese, Sunday, Oct 18, 2009...

By TOM MALITI, Associated Press Writer Tom Maliti, Associated Press Writer – Mon Oct 19, 3:44 pm ET

KASESE, Uganda – For years, Charles Wesley Mumbere worked as a nurse’s aide in Maryland and Pennsylvania, caring for the elderly and sick. No one there suspected that he had inherited a royal title in his African homeland when he was just 13.

On Monday, after years of political upheaval and financial struggle, Mumbere, 56, was finally crowned king of his people to the sound of drumbeats and thousands of cheering supporters wearing cloth printed with his portraits.

At a public rally later in the day, Ugandan President Yoweri Museveni officially recognized the 300,000-strong Rwenzururu Kingdom. Museveni restored the traditional kingdoms his predecessor banned in 1967, but has been adamant that kings restrict themselves to cultural duties and keep out of politics.

“It is a great moment to know that finally the central government has understood the demands of the Bakonzo people who have been seeking very hard for recognition of their identity,” Mumbere told The Associated Press in the whitewashed single-story building that serves as a palace.

The Rwenzururu parliament sits nearby, in a much larger structure made of reeds. It was here the traditional private rituals were held Sunday night and Monday morning to crown Mumbere king.

Thousands walked several miles (kilometers) to see Mumbere, dressed in flowing green robes and a colorful hat, be officially recognized.

Old men clutching canes shuffled up the hill beside women in colorful Ugandan dresses called “gomesi.” Among them was Masereka Tadai, 43, proudly overseeing practice for a march that retired scouts and girl guides would perform before the king.

“Everyone is very happy because the president has accepted to come here and officially recognize the Rwenzururu Kingdom,” Tadai said over a nearby drumbeat.

The new King of Uganda’s Mountains of the Moon has undergone many transformations — from teenage leader of a rebel force to impoverished student to a nursing home assistant working two jobs in the U.S., where he lived for nearly 25 years.

Mumbere’s royal roots only became public in Pennsylvania this July, when he granted an interview to The Patriot-News of Harrisburg as he was preparing to return to Uganda.

He inherited the title when his father, Isaya Mukirania Kibanzanga, died while leading a secessionist group in the Rwenzori Mountains, otherwise known as the Mountains of the Moon. The rebels were protesting the oppression of their Bakonzo ethnic group by their then-rulers, the Toro Kingdom.

The Bakonzo demanded to be recognized as a separate entity and named Kibanzanga, a former primary school teacher, as their king in 1963.

“It was very difficult growing up in the bush,” remembered Mumbere, who was 9 years old when his father took the family into the mountains. Although he received military training, Mumbere did not fight.

“Our country has been independent (from the British) for 40-something years but in Rwenzururu you may not find running water, there are no hospitals,” Mumbere said.

Shortly after Kibanzanga died, his son led the fighters down from the mountains to hand in their weapons. Mumbere went to the United States in 1984 on a Uganda government scholarship, attending a business school until Uganda’s leadership changed and the stipend was stopped. He gained political asylum in 1987, trained as a nurse’s aide and took a job in a suburban Washington nursing home to pay his bills, said The Patriot-News of Harrisburg in a July 2009 story.

In 1999, he moved to Harrisburg, Pennsylvania’s capital, where he worked for at least two health care facilities.

He was “very loyal, a very hard worker, a very private person,” said Johnna Marx, executive director of the Golden Living Center-Blue Ridge Mountain on the outskirts of Harrisburg.

Mumbere said he chose to train as a nurse’s aide because the work, “was more reliable. Other jobs you can be laid off easily.”

Living in the U.S., however, was “a very difficult experience,” he said. “Sometimes you have two jobs. You go to college in the morning, between 8 a.m. to 12 p.m. Then you go prepare to go to work at 3 p.m. and then return at 11 p.m.”

He is now a green card holder, and his son and daughter live in Harrisburg. But he never forgot the people he left behind. When the Ugandan government decided to reinstate the traditional kingdoms, Mumbere lobbied the Rwenzururu Kingdom to be among them.

After 10 years of negotiation, President Museveni announced in August the government would recognize the Rwenzururu Kingdom as Uganda’s seventh kingdom. Government recognition does not grant any executive power but allows the monarchs to determine cultural and social issues affecting their people.

• Slideshow:Nurse’s aide crowned a Ugandan king

Donate to Your Favorite Charity Everyday…. At No Cost To You

In these hard economic times NGOs are feeling the pinch just like everyone else.  Although our wallets have gotten smaller I know that our hearts have not.  There are still people to help and causes to support.  The question is, how can we get it all done?  Well, it may not be as hard as you think.  You can donate to your favorite charity everyday simply by using the internet.  There are two new tools available to help.

GoodSearch.com is a Yahoo-powered search engine that donates half its advertising revenue, about a penny per search, to the charities its users designate. Use it just as you would any search engine, get quality search results from Yahoo, and watch the donations add up!

GoodShop.com is a new online shopping mall which donates up to 37 percent of each purchase to your favorite cause.  Hundreds of great stores including Amazon, Target, Gap, Best Buy, ebay, Macy’s and Barnes & Noble have teamed up with GoodShop and every time you place an order, you’ll be supporting your favorite charity.

To find out more go to www.goodsearch.com.  Be sure to enter Psychology Beyond Borders as the charity you want to support.

Did John Wayne ever have PTSD? Toughness and Trauma

Are there certain types of people who do better at handling traumatic events than others?  Almost certainly – as discussed earlier on this blog, a variety of differences in things such as emotional expressivity and physiological reactivity can predict people’s responses to traumatic events.  But that’s not the interesting question.  After all, there are individual differences in almost every psychological phenomenon you can find.  The interesting question (at least to me) is this: is pop culture accurate as to what kind of person can best cope with traumatic events?  Is there a kernel of truth to the idea of “toughness?”  Does the stereotypical image of a rough, tough, macho man (or woman) who can eat nails and spit bullets have any relevance to the actual psychological predictors that can help predict a healthy response to a traumatic event?   Some insight on this question comes from a chapter written by Patricia Watson and colleagues published in the book “Interventions following mass violence and disasters: Strategies for mental health practice”  (Ritchie, Watson, & Friedman, 2006). Watson et al’s chapter looks at what predicts healthy resilience following disasters and mass traumas.  As a part of that, they brush up against many of the things that characterize a traditional tough-guy/gal, and paint an interesting picture of whether Hollywood got it right.  Let’s see how the image of a tough person holds up by looking at the research behind some traditional characteristics that show up in “tough” characters on TV and in movies:

1.    A tough guy/gal is capable, and knows how to handle any event. This type of confidence is referred to as “coping self-efficacy,” a relatively fancy term that basically means that people have a perception of themselves as able to effectively handle stressful or negative events.  If someone believes that they can appropriately handle anything life throws at them, they’re much more likely to recover from any specific stressful event.  Whether it’s through building machines like MacGuyver or just gunning down anyone who gets in her way like Vazquez from the movie Aliens, the traditional tough-guy/gal can handle anything that comes their way – and this means that they will probably recover well from a traumatic event.

2.    A tough guy/gal started out green and “toughened up.” The research on this suggests this can be true.  Repeated exposure to challenges or stressors, if followed by good recovery periods, can help to keep the body’s system used to responding to and recovering from stressful events .  This can reduce long-term distress.  Importantly, however, this only works if the stressful event is something that does not itself cause long-term distress.  Situations which included loss, or emphasize that the person is not in control of their life can be bad, and can weaken instead of improve people’s overall resilience.

3.    A tough guy/gal is fit. Physical fitness is important for every kind of health – including mental health!  People who are in good shape are both more likely to have had repeated demonstrations of their ability to handle challenging situations (through the challenging process of getting fit) and are also more likely be able to respond in a healthy fashion to the physiological response to stressors.

4.    A tough guy/gal is a loner, who works best alone and broods over their past with a glass of straight whisky. Uh-oh.  Now, our tough guy/gal has a serious problem.  This pattern of characteristics that is so popular in our images of tough heroes that it has become a cultural stereotype is almost exactly the opposite of the best way to respond to a traumatic event.  Research consistently shows, over and over again, that the people who recover best from traumatic events are people who seek help from others, and build large social networks that provide critical social support.  Talking to others about the traumatic event (when they want to), and spending time with others in healthy, positive social interactions, helps to support healthy coping strategies.  This allows people to see themselves in a positive light, improves perceptions of mastery and helps with constructing a narrative of the traumatic event that provides meaning, an important predictor in recovery.  Moreover, using alcohol as a way of coping with a traumatic event is a bad idea – it does not contribute to long-term mental health, may exacerbate feeling badly, and can easily lead to more significant problems down the road.

So overall, what does this suggest about our images of toughness?  There are some good ideas there.  Physical fitness, self-confidence and mastery, and a history of successfully managed stressful events can all help to improve response to traumatic events, and someone who works to develop those traits will probably show more healthy long-term responses to trauma than those without them.  But the image that often goes with those traits in popular culture, of a person who holds themselves separate from the rest of the world and works as a “lone wolf”… well, it’s a powerful image and one that is tempting to many people.  But the research is clear: lone wolves don’t work as well as those who have a pack.  Social engagement and positive social interactions are one of the best ways to recover from a traumatic event.  If you define toughness as the ability to overcome anything that life throws at you, then the toughest person in the room is not likely to be the Indiana Jones lookalike brooding alone at the end of the bar.  It’s probably the person surrounded by her friends, and having a positive, cheerful time.

Are there certain types of people who do better at handling traumatic events than others?  Almost certainly – as

discussed earlier on this blog, (http://beyondfearblog.wordpress.com/2009/08/19/gender-and-ptsd) a variety of

differences in things such as emotional expressivity and physiological reactivity can predict people’s responses

to traumatic events.  But that’s not the interesting question.  After all, there are individual differences in

almost every psychological phenomenon you can find.  The interesting question (at least to me) is this: is pop

culture accurate as to what kind of person can best cope with traumatic events?  Is there a kernel of truth to

the idea of “toughness?”  Does the stereotypical image of a rough, tough, macho man (or woman) who can eat nails

and spit bullets have any relevance to the actual psychological predictors that can help predict a healthy

response to a traumatic event?   Some insight on this question comes from a chapter written by Patricia Watson

and colleagues published in the book “Interventions following mass violence and disasters: Strategies for mental

health practice”

(http://www.amazon.com/Interventions-Following-Mass-Violence-Disasters/dp/1593852568/ref=ed_oe_h) (Ritchie,

Watson, & Friedman, 2006).
Watson et al’s chapter looks at what predicts healthy resilience following disasters and mass traumas.  As a

part of that, they brush up against many of the things that characterize a traditional tough-guy/gal, and paint

an interesting picture of whether Hollywood got it right.  Let’s see how the image of a tough person holds up by

looking at the research behind some traditional characteristics that show up in “tough” characters on TV and in

movies:
1.    A tough guy/gal is capable, and knows how to handle any event.  This type of confidence is referred to

as “coping self-efficacy,” a relatively fancy term that basically means that people have a perception of

themselves as able to effectively handle stressful or negative events.  If someone believes that they can

appropriately handle anything life throws at them, they’re much more likely to recover from any specific

stressful event.  Whether it’s through building machines like MacGuyver or just gunning down anyone who gets in

her way like Vazquez from the movie Aliens, the traditional tough-guy/gal can handle anything that comes their

way – and this means that they will probably recover well from a traumatic event.
2.    A tough guy/gal started out green and “toughened up.”  The research on this suggests this can be true.

Repeated exposure to challenges or stressors, if followed by good recovery periods, can help to keep the body’s

system used to responding to and recovering from stressful events .  This can reduce long-term distress.

Importantly, however, this only works if the stressful event is something that does not itself cause long-term

distress.  Situations which included loss, or emphasize that the person is not in control of their life can be

bad, and can weaken instead of improve people’s overall resilience.
3.    A tough guy/gal is fit.  Physical fitness is important for every kind of health – including mental

health!  People who are in good shape are both more likely to have had repeated demonstrations of their ability

to handle challenging situations (through the challenging process of getting fit) and are also more likely be

able to respond in a healthy fashion to the physiological response to stressors.
4.    A tough guy/gal is a loner, who works best alone and broods over their past with a glass of straight

whisky.   Uh-oh.  Now, our tough guy/gal has a serious problem.  This pattern of characteristics that is so

popular in our images of tough heroes that it has become a cultural stereotype is almost exactly the opposite of

the best way to respond to a traumatic event.  Research consistently shows, over and over again, that the people

who recover best from traumatic events are people who seek help from others, and build large social networks

that provide critical social support.  Talking to others about the traumatic event (when they want to), and

spending time with others in healthy, positive social interactions, helps to support healthy coping strategies.

This allows people to see themselves in a positive light, improves perceptions of mastery and helps with

constructing a narrative of the traumatic event that provides meaning, an important predictor in recovery

(http://beyondfearblog.wordpress.com/2009/06/29/can-political-commitment-protect-people-from-ptsd/).  Moreover,

using alcohol as a way of coping with a traumatic event is a bad idea – it does not contribute to long-term

mental health, may exacerbate feeling badly, and can easily lead to more significant problems down the road.
So overall, what does this suggest about our images of toughness?  There are some good ideas there.  Physical

fitness, self-confidence and mastery, and a history of successfully managed stressful events can all help to

improve response to traumatic events, and someone who works to develop those traits will probably show more

healthy long-term responses to trauma than those without them.  But the image that often goes with those traits

in popular culture, of a person who holds themselves separate from the rest of the world and works as a “lone

wolf”… well, it’s a powerful image and one that is tempting to many people.  But the research is clear: lone

wolves don’t work as well as those who have a pack.  Social engagement and positive social interactions are one

of the best ways to recover from a traumatic event.  If you define toughness as the ability to overcome anything

that life throws at you, then the toughest person in the room is not likely to be the Indiana Jones lookalike

brooding alone at the end of the bar.  It’s probably the person surrounded by her friends, and having a

positive, cheerful time.

9/11 National Day of Service and Remembrance

As the United States approaches the 8th anniversary of the terrorist attacks of 9/11/01, we also launch the first “9/11 National Day of Service and Remembrance”

All across the United States as well as globally, people are putting together service plans and deciding on good deeds to conduct.

As an organization dedicated to addressing the emotional aftermath of disasters, terrorism and armed conflict, Psychology Beyond Borders is eager to hear what kinds of events people are planning for this September 11, 2009.

Please let Psychology Beyond Borders know what you are planning to do on this, our nation’s first official National Day of Service and Remembrance. Link to our blog www.beyondfearblog.org and share your plans with our audience. Or go to our Facebook page.

We are eager to hear from you and hope that you feel the sense of connection to the people you serve and the rest of the world when you accomplish your service goals for 9/11/09.

For those of you interested in the 9/11/01 Memorial Information please visit http://national911memorial.org

Visit the Psychology Beyond Borders website at www.psychologybeyondborders.org for more information and resources on managing the psychological impact of disasters, terrorism and armed conflict.

I sincerely hope you are able to participate in the National Day of Service and as we honor those who died on 9/11 eight years ago, bring some joy to others in their memory. May that joy come back to you.

Psychosocial Worker Progresses in Uganda

Very good news. We have been waiting to hear about what has been happening with our friend, Simon Peter, in Soroti, Uganda and now hear that  Simon has been accepted at the Ugandan Management Institute for a PostGraduate Diploma in Project Planning and Management. Simon is a psychosocial worker with TPO in Uganda an wanted to continue his education in program planning at the University of Australia, but the cost was prohibitive.

Several U.S. supporters pledged to try and help Simon if he found a program that was within a more feasible price range. He searched and applied to a few different places. Here is the note announcing his find:

“Hi April,

Iam sorry for inconviniencing you and thank you for enduring with me.

Please find attached details of my admission. It is a weekend Postgraduate deploma that subsequentlly shall lead to a masters degree in PPM. The whole Posgraduate Diploma Tution will be 1000 US Dollars Minus Transport. Then the final stage for masters may be 3000 US Dollars with apparent Exchange rate of 1USD Equivalent to 2100 Uganda Shillings.

I am settled now to have my masters locally as i continue working possibly that is how God wanted.

 Good night and happy weekend”

So, I congratulated Simon, sent his registration fees and asked for some more details. His response is a stark example of much sacrifice he has to make just to take a local postgraduate course. See for yourselves:

“Hi April,

I hope i do not over load you. I will be taking public means- Bus or Mini Taxi which takes 6-7 hours and costing 30,000/= (Ugandan Shillings) to and from Soroti. I will also be travelling every friday and back on sunday evening. In Gulu i have already got accomodation from afriend. Other wise i will face T/port and accomodation.

Thanks

Simon”

Congratulations, Simon Peter! BTW, I’ve asked Simon if we can share his communications and progress as many people have offered to help and have been wondering what is happening. We are hoping for a picture of Simon soon and continuing news of his progress. Education for someone like Simon who is already working within his own community can really strengthen the sustainability of his work and those of his colleagues. We are so thrilled for Simon and those who he will continue to serve in Uganda.

Looking at the Long Term

The most recent count yesterday totaled 461 dead and 192 missing. And it’s only been 2 1/2 weeks since Typhoon Morakot hit Taiwan, dumping 118 inches of rain on the island off the coast of China. Floods and landslides are reported to be most to blame for the damage, as the typhoon was very large and very slow-moving. These images of the damage speak for themselves.

The typhoon struck at a coincidental time for PBB. Less than a week after Typhoon Morakot broke land, PBB staff traveled to Galveston, Texas to do an anniversary training for the Hurricane Ike relief teams. PBB’s staff, April Naturale and Conor Seyle, trained over 150 crisis counselors on what they should expect from their communities around the anniversary of a major community disaster. I can’t help but wonder what the communities affected by Typhoon Morakot will be experiencing one year from now.

It is this forward-thinking “intermediate phase” aid with which PBB is most concerned. After the basic needs of food, safety and shelter are met and the community members have regained a sense of stability, only then are we in a place to offer psychological assistance. It is important to note, however, that not every community affected by disaster will need outside help. Most individuals and communities have an inherent sense of resiliency, and for many, that is more than enough to help them through the long process of recovery. But for those other communities that do need a level of professional aid, PBB is willing and able to work with and build upon their local supports to create lasting partnerships and sustainable services. For instance, we are on the tail end of our project in Yogyakarta, Indonesia, providing skills-based psychosocial training to a community that was affected by an earthquake 3 years ago. And the War Affected Youth we are beginning to be involved with in Sierra Leone stopped fighting their civil war in 2002.

We all know it is easier to give to a cause when the damage is recent and the need is immediate. But what about a year or two or seven after the trauma, and there is still work to be done? Please support PBB in our long-term vision for relieving psychological suffering. The communities of the forgotten disasters will be grateful.

Gender and PTSD

I was just reading an edited volume on the issue of gender and PTSD (appropriately enough, titled “Gender and PTSD” (Kimmerling, Ouimette, & Wolfe, 2002)).  It’s an excellent book, and one of the most systematic reviews of the literature surrounding a truly interesting issue in PTSD research that I’m aware of.  The basic issue is this: internationally and consistently across studies, men are shown to be exposed to significantly more traumatic events than women. Despite this, women are much more likely to have PTSD.

In their day-to-day lives, men are much more likely to be the victims of violence.  In the U.S., various studies (reported in Norris, Foster, & Weisshaar 2002 – the first chapter of Gender and PTSD) have found rates of exposure to trauma ranging from 61%-81% in men, and 54%-74% in women.  Women’s exposure rates are consistently lower than men’s.  Despite this, the lifetime prevalence of PTSD is consistently about twice as high in women as in men.  Studies have found rates around 10-11% in women, and 5-6% in men.  So there is an interesting disconnect in the data.  Even with the fact that men are more likely to experience traumatic events, women are overall more likely to show PTSD.

What explains this?  This is a large and active field of research, so there is as of yet no single accepted answer.  There are a couple of ideas that have been studied, however.  One possibility is that men experience more trauma, but women experience kinds of trauma that are more psychologically distressing.  It is certainly the case that experiences of trauma differ.  Men are much more likely to experience combat, physical assault, and car accidents than women, while women are more likely to experience sexual assault than men.  It is entirely possible that this difference explains a great deal of the effect.  However, it does not explain all of it – a study that specifically looked at rates of conditional risk (the likelihood of experiencing PTSD after a traumatic event) found that women’s rates of conditional risk were higher for every category of traumatic event with the exception of rape, where conditional risk was about equal between women and men.  This suggests that something else is happening that leads to the gender differences found.

Another explanation is biological.  The second chapter of Gender and PTSD, by Rasmussen & Friedman, discusses the (extremely limited) literature looking at the physiology of PTSD in men and women.  There has not been much work done in this area, but the existing research does suggest that there are some physiological differences in stress response both between women and men and within women across the menstrual cycle.  In several specific ways, women have been found to show responses to stressors more similar to people with PTSD, when compared to men.  For example, some studies have found that women and female animals release less Neuropeptide Y in response to stressors than males do.  A reduced NPY response is one physiological response associated with PTSD.  This research is developing, and may serve as an important perspective in the question of gender and PTSD.  However, as it stands it is not a complete answer to the question.

A third explanation is more social/cognitive.  The psychological experience of a traumatic event is a critical mediator of long-term distress.  Those people who experience more distress are much more likely to have long-term problems.  In part, this is a physiological issue: more reactivity means more experience of distress.  But in part, it’s also a reflection of the individual’s beliefs and interpretation of the event.  If someone feels that a traumatic event was strongly negative, and blames themselves, then they will probably show more long-term distress. There is evidence that women are much more likely to view the world as threatening, and also to blame themselves following traumatic events (discussed in chapter 3 of the Gender and PTSD book, by Tolin & Foa).  This also dovetails neatly with cross-cultural research showing that cultures which have strict gender roles that discourage men from expressing emotion show stronger differences between men and women in PTSD than those which are more equal in gender expression.  It may be that in these cultures, women are allowed or even encouraged to focus on their negative emotional reaction to traumatic events in a way that men are not.  This, in turn, leads to differences in their interpretation of the event and to more significant long-term distress.

In many ways, any question about sex or gender differences is another version of the age-old nature versus nurture debate.  Those who would emphasize biological differences as the cause of these differences emphasize the “nature” part, while those who point to culture emphasize the “nurture.”  Most likely, this research, like almost all the research into this question, will resolve eventually not into the question of which approach is right, but instead how the “nature” variables interact with the “nurture” context to produce behavior.  At the current state of the research, though, this remains an interesting puzzle for researchers – and a challenge for women exposed to traumatic events across the world.

I was just reading an edited volume on the issue of gender and PTSD (appropriately enough, titled “Gender and PTSD” (Kimmerling, Ouimette, & Wolfe 2002). It’s an excellent book, and one of the most systematic reviews of the literature surrounding a really interesting issue in PTSD research that I’m aware of. The basic issue is this: internationally and consistently, men are exposed to significantly more traumatic events than women. In their day-to-day lives, men are much more likely to be the victims of violence. In the U.S., various studies (reported in Norris, Foster, & Weisshaar 2002 – the first chapter of Gender and PTSD) have found rates of exposure to trauma ranging from 61%-81% in men, and 54%-74% in women. Women’s exposure rates are consistently lower than men’s. Despite this, the lifetime prevalence of PTSD is consistently about twice as high in women as in men. Studies have found rates around 10-11% in women, and 5-6% in men. So there is an interesting disconnect in the data. Even with the fact that men are more likely to experience traumatic events, women are overall more likely to show PTSD.

What explains this? This is a large and active field of research, so there is as of yet no single accepted answer. There are a couple of ideas that have been studied, however. One possibility is that men experience more trauma, but women experience kinds of trauma that are more psychologically distressing. It is certainly the case that experiences of trauma differ. Men are much more likely to experience combat, physical assault, and car accidents than women, while women are more likely to experience sexual assault than men. It is entirely possible that this difference explains a great deal of the effect. However, it does not explain all of it – a study that specifically looked at rates of conditional risk (the likelihood of experiencing PTSD after a traumatic event) found that women’s rates of conditional risk were higher for every category of traumatic event with the exception of rape, where conditional risk was about equal between women and men. This suggests that something else is happening that leads to the gender differences found.

Another explanation is biological. The second chapter of Gender and PTSD, by Rasmussen & Friedman, discusses the (extremely limited) literature looking at the physiology of PTSD in men and women. There has not been much work done in this area, but the existing research does suggest that there are some physiological differences in stress response both between women and men and within women across the menstrual cycle. In several specific ways, women have been found to show responses to stressors more similar to people with PTSD, when compared to men. For example, some studies have found that women and female animals release less Neuropeptide Y in response to stressors than males do. A reduced NPY response is one physiological response associated with PTSD. This research is developing, and may serve as an important perspective in the question of gender and PTSD. However, as it stands it is not a complete answer to the question.

A third explanation is more social/cognitive. The psychological experience of a traumatic event is a critical mediator of long-term distress. Those people who experience more distress are much more likely to have long-term problems. In part, this is a physiological issue: more reactivity means more experience of distress. But in part, it’s also a reflection of the individual’s beliefs and interpretation of the event. If someone feels that a traumatic event was strongly negative, and blames themselves, then they will probably show more long-term distress. There is evidence that women are much more likely to view the world as threatening, and also to blame themselves following traumatic events (discussed in chapter 3 of the Gender and PTSD book, by Tolin & Foa). This also dovetails neatly with cross-cultural research showing that cultures which have strict gender roles that discourage men from expressing emotion show stronger differences between men and women in PTSD than those which are more equal in gender expression. It may be that in these cultures, women are allowed or even encouraged to focus on their negative emotional reaction to traumatic events in a way that men are not. This, in turn, leads to differences in their interpretation of the event and to more significant long-term distress.

In many ways, any question about sex or gender differences is another version of the age-old nature versus nurture debate. Those who would emphasize biological differences as the cause of these differences emphasize the “nature” part, while those who point to culture emphasize the “nurture.” Most likely, this research, like almost all the research into this question, will resolve eventually not into the question of which approach is right, but instead how the “nature” variables interact with the “nurture” context to produce behavior. At the current state of the research, though, this remains an interesting puzzle for researchers – and a challenge for women exposed to traumatic events across the world.

The Threat to Humanitarian Aid Workers July 29, 2009

By April Naturale, PBB CEO

Historically, Humanitarian Aid workers and others, like journalists, who go into high-risk areas affected by disaster and war have been somewhat protected. While there certainly were some accidents and a few isolated incidents of being targeted by terrorists, these groups were untouched–allowed to move into affected areas to provide health care, food and shelter, a shoulder to cry on and emotional support. The legal basis for protection of humanitarian workers in conflicts is contained in the Geneva Conventions of 1949 and the related Protocol of 1977.

Such protection, while still the legal ruling, seems to no longer be the case on the ground. A scheduled training by Psychology Beyond Borders for the aid workers in the Central African Republic was canceled earlier this year as the country was no longer safe for those bringing much needed help. Aid workers in Darfur have been attacked, detained and arrested while entire organizations have been expelled from the country.

Just as the U.S. was shocked by the murder of almost 3,000 civilians in the terrorist attacks of 2001, many countries continue to see such incidents in public places. The bombing in Jakarta, Indonesia on Friday, July 17^th was the first the area has seen in over three years. Still, it’s shocking.

The building next to the Australian Embassy in Jakarta affected by the bombing.

A doctoral student from the University of California, Irvine, acting as a volunteer for Psychology Beyond Borders, was actually scheduled to depart from the Jakarta airport that morning. Because we needed her to bring medical equipment into Yogyakarta and it was easier to have our University of Sanata Dharma partners meet her there, her flight was changed to leave directly out of Yogya. How fortunate is she?

Humanitarian aid workers, researchers, our colleagues in the fields of public health and journalism. We have new and serious considerations to make when engaging in international work. Natural disasters and terrorism are on the rise. Armed conflicts continue to threaten many nations. Our work is needed more than ever.

How do we protect ourselves when the Geneva Conventions aren’t even being adhered to?

Are agencies seeing fewer workers and volunteers willing to enter high-risk areas? Do we need to change our policies about volunteers vs. staffs and begin integrating security staffs into our budgets? (As if we could!)

Sierra Leone Post-visit Report

by April Naturale, PBB CEO

5.22.09

It is a long way from Boston, USA to Freetown in Sierra Leone on the continent of Africa. The return seems even longer. The time spent interacting with the Sierra Leoneans was anything but tiring. If there were ever a people who exemplify an ability to overcome adversity, at least on a psychological level, Sierra Leoneans seem to be that people.

It’s almost seven years since the war here ended. It is known as one of the most barbaric wars with some of the worst of atrocities known to man having been committed for years from one end of the country to the other. The worst part of the story is that much of the inhumane acts were committed by children forced under threat of death and dismemberment along with mind-numbing drugs.

The first actions taken by most families and non-governmental organizations that entered the country to help was to reunify loved ones. This included disarmament and demobilization and well as rehabilitation and reintegration of those youth who had been so cruelly pulled from their communities and psychologically tortured. Rebuilding the physical structures continues, but this country is largely dependent on aid just to survive with the basic supports such as food and safety.

Sierra Leone has historically been on the lowest end of the human index scale and is largely dependent on aid. The war exemplified their pre-existing problems. And now, ten years later, the country, and these vulnerable children and youth, are still at risk. Some of those who were associated with armed forces and armed groups have lost their families, lost limbs and many lost their sense of self. They were pulled out of school, away from family and forced (directly and indirectly) to enact atrocities upon each other, those they loved and their country. Many still suffer with substance abuse problems as a result of being shot up with drugs by rebels threatening to cut off an arm or kill them if they didn’t participate.

Returning to a life after war has found most of these youth without a completed education or skills to contribute to community life. Many were too afraid or ashamed to return to what family may have been left. Others were not accepted back into their communities.

There is opportunity to help those who remain hopeful that they and their families might build some normal semblance of a life. I met two students who were full of life and hope–Dominic and Benjamin. They are lucky, but still at risk of the threat of violence due to the fragile peace in Sierra Leone and the neighboring fighting forces.

Others are not so lucky. Their families don’t have the funds to send them to school. They don’t even have the funds for proper clothing.

I asked Biawama (I know I’m not spelling his name right; top) if he went to school and after a brief silence, with a bowed head he said yes. Clearly he had not been there along with Dominic and Benjamin, but he was ashamed to say no. Bomoi (bottom) had chores to do. I helped him carry his two heavy bottles of water. He had no English at all which was an indication he was not attending school. English is required at all levels in Sierra Leone and the children are the most proficient.

Psychology Beyond Borders plans to return to Freetown in September and continue planning with local psychosocial organizations and our collaborators at the Research Program on Global Adversity as to how to move forward. Education, skills building, counseling, community psychoeducation …these are all our early ideas that show an evidence-informed chance of actually helping. Keep posted for our follow up activities and check out the website for the next podcasts from former child soldiers.