de Jong, K

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BMJ Group blogs: BMJ » Blog Archive » Kaz de Jong: What is a traumatic experience if you live in Mogadishu?
http://blogs.bmj.com/bmj/2012/03/05/kaz-de-jong-what-is-a-traumatic-experience-if-you-live-in-mogadishu-2/[3/12/2013 4:49:15 PM]
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Kaz de Jong: What is a traumatic experience if you
live in Mogadishu?
5 Mar, 12 | by BMJ Group
The woman in
front of me in the
clinic looked worried. Her child, a small creature,
was struggling to resist efforts to measure his
weight. She was worried about him and his safety
in their war-torn home city of Mogadishu,
Somalia. While waiting, we talked about her
conflict related experiences of the past 25 years.
She described a long list of events, each of which
would qualify for the label “potentially traumatic” in
western settings. She did not suffer from any
symptoms related to trauma, anxiety, or
depression. I wondered: what events are traumatising in Mogadishu? Are there different
criteria to qualify for the diagnosis of PTSD (post-traumatic stress disorder)? Does it
even exist in these settings?
There is common agreement on the priority setting and focus of mental health
interventions in humanitarian emergencies, which is described in the IASC guidelines. A
recent consensus based agenda for mental health and psychosocial research priorities
in humanitarian settings largely focused on generating practical knowledge for
immediate benefit to programmes. Debates on the cross-cultural relevance of western
mental health diagnoses based on DSM IV criteria (such as PTSD) were considered
less important. This largely academic debate did not result in substantial progress in
service accessibility, best practice in interventions, or knowledge about mental suffering
in different cultures. The last thing I want to do is to restart this unproductive discussion.
Nevertheless, to deprioritise it has risks.
Not only culture, but context is important. My work with Médecins Sans Frontières brings
me into contexts devastated by acute, ongoing, or very recent mass violence or natural
disaster. Often I experience how difficult it is to capture the suffering of affected
populations in frameworks developed in peaceful contexts; even when these have been
developed within the same culture. Working in areas of immediate disaster or acute
violence may require a different approach.
Research in contexts of ongoing violence is difficult and dangerous and most mental
health research is executed in non-conflict or post-conflict settings. Research in the
direct aftermath of natural disasters, ongoing conflict, acute humanitarian crisis (even up
to 4 years after a conflict has ended), is rare. The findings from peaceful or post-conflict
areas have commonly been generalized and used in areas of acute, ongoing violence.
Do we fully realize the scope of this potential generalisation error?
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BMJ Group blogs: BMJ » Blog Archive » Kaz de Jong: What is a traumatic experience if you live in Mogadishu?
http://blogs.bmj.com/bmj/2012/03/05/kaz-de-jong-what-is-a-traumatic-experience-if-you-live-in-mogadishu-2/[3/12/2013 4:49:15 PM]
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For survivors there is a difference in the experience and labelling of anxiety after a
natural disaster and during an ongoing conflict, and similarly between their perception of
anxiety during and after war. I was confronted with this when I assessed psychosocial
mental health needs in Mogadishu. Like the mother I met with her child, nearly all our
clinic attendants reported a series of extreme confrontations with violence. However,
only half those interviewed could describe a particularly upsetting event. Horwitz and
Wakefield suggested that people living in areas of violence only perceive and report
violent events as traumatising when they are out of proportion to the context. Our
recently published research in Mogadishu confirms this.
Our data also suggest that simplified indicators such as ‘being able to describe a
particularly upsetting event’ may suffice in time-limited assessments for psychosocial or
mental health vulnerability in highly unpredictable, insecure and resource-poor situations
of mass violence. Using a more neutral indicator instead of a mental health diagnosis
such as PTSD avoids the stigma of a psychiatric diagnosis and the cross-cultural
validity constraints of these labels. After more than a decade of pursuing controversial
DSM-related indicators, it might be time for a more pragmatic approach that focuses on
vulnerability rather than diagnosis.
To distinguish indicators of mental health vulnerability in areas of acute, ongoing
violence from indicators used in other contexts also has implications for how these
interventions are evaluated. A redefinition from clinical, diagnostic criteria to other
indicators of success is necessary. This would relieve both practitioners and mental
health researchers from difficulties that arise when a strict DSM approach is followed in
these settings. And more importantly it would provide a simple method to identify and
focus on the current psychosocial needs of the most vulnerable people whose daily
lives are affected by conflict.
Kaz de Jong, Mental Health Specialist, Médecins Sans Frontières, Amsterdam,
Netherlands
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BMJ Group blogs: BMJ » Blog Archive » Kaz de Jong: What is a traumatic experience if you live in Mogadishu?
http://blogs.bmj.com/bmj/2012/03/05/kaz-de-jong-what-is-a-traumatic-experience-if-you-live-in-mogadishu-2/[3/12/2013 4:49:15 PM]
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What is a traumatic experience if you live in Mogadishu?

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What is a traumatic experience if you live in Mogadishu?

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