Assessing psychosocial distress which lens?

Over the past three decades, there has been a rapid growth in humanitarian interventions attempting to address the psychosocial distress caused by violence and forced displacement. A wide and diverse range of practice has emerged, reflecting different ways of assessing and understanding psychosocial distress. This article highlights some of the assumptions underlying these different approaches, and how these may inform subsequent practice. As detailed below, a ‘culturally relativistic’ approach attempts to take the point of view of the insider. By applying this approach among a Masaalit community in Darfur, we have been able to gather detailed information about the beneficiaries’ perspectives on psychosocial distress. Within this particular turbulent context, the results suggest a need to focus on mainstreaming positive psychosocial outcomes across different sectoral domains.

Stress and distress

In many societies, ‘stress’ has become a widely used metaphor for personal and collective suffering, covering a range of negative feelings and physical sensations. In most cases, these feelings or sensations are usually explained as reactions to adverse external circumstances. As such, responsibility for suffering tends to be located beyond the individual. Stress at moderate levels can help us react and adapt to a situation. However, if persistent or excessive it can seriously affect our physical, mental, social and spiritual well-being. It is at this stage that stress becomes ‘distress’.

Every culture provides its members with recognisable languages of distress with which to communicate their suffering. If we are able to understand this language, which may be verbal or non-verbal, physical or psychological, our humanitarian interventions may be better informed.

Three lenses

While violent conflict and forced displacement can have a profound impact on people’s psychosocial well-being, the processes by which it affects them nevertheless remain unclear. Not all people respond to disastrous events in a similar way, nor are they likely to have the same needs. Agencies attempting to assess the psychosocial impact of violence and displacement tend to use one, or a combination, of three approaches – universal, transcultural and relativist. Within each approach, a set of assumptions informs assessment tools, analysis of data and subsequent practice. With the forthcoming release of the Inter-Agency Standing Committee’s (IASC) guidelines on ‘Mental Health And Psychosocial Support In Emergency Settings’, there appears to be an emerging consensus on what constitutes recommended practice. While this may encourage a shift towards better practice, it is nonetheless important to consider how assessment methodologies inform different notions of psychosocial distress.

Universal lens

Those who take a universal view of humanity see Western psychiatric models as universally valid and relevant, irrespective of time and culture. Stress reactions are seen to have a universal, neurobiological core (neurobiology is the biology of how the brain functions). Distress is thought to manifest itself in the form of psychiatric disorders, and it is assumed that these disorders remain constant across different cultures. By means of illustration, Post Traumatic Stress Disorder (PTSD) is a psychiatric diagnosis associated with people who have been exposed to a historical event, which may be considered traumatic. A set of symptoms, or criteria, is set out within a standard international diagnostic classification system. If a clinically trained practitioner identifies six criteria – including intrusive recollection, avoidance behaviour or hyper-arousal over a specified period of time – the patient receives a psychiatric diagnosis of PTSD. Within a Western context, there are a number of evidence-based therapeutic approaches, including counselling, which can be used to treat this disorder.

A number of screening instruments or questionnaires have been developed for assessing the prevalence of PTSD among refugees, such as the Harvard Trauma Questionnaire (HTQ). Within the context of a complex emergency, some practitioners have attempted to use these instruments to assess the prevalence of PTSD across war affected non-Western populations. This approach tends to show a comparatively high frequency of symptom reportage among war-affected communities. As the assessment is framed in terms of mental ill-health, humanitarian responses may include psycho- educational or trauma-related programmes. Some researchers have used this method in an attempt to compare the prevalence of PTSD across different populations, and subsequently attempt to identify protective factors.

Transcultural psychiatry lens

A number of practitioners have questioned the validity and cultural relevance of the kind of universal, standardised diagnostic framework described above within non-Western, war-affected populations. Instead, they assert that distress is expressed differently across different cultures. For example, a local population may have their own important categories or local idioms of distress, but these may not correspond to symptoms of PTSD. It is argued that Western symptom checklists, based on international psychiatric classification systems, do not capture the range of ways in which non-Western populations express their distress.

Some researchers attempt to translate and adapt Western diagnostic instruments, or symptom checklists, for use in non-Western cultures. In recognising that symptoms associated with a disorder in one culture may not necessarily indicate that same disorder in another culture, it is essential to test the equivalence between the original and the translated instrument. A properly adapted transcultural diagnostic instrument requires significant research time and resources. In the midst of an emergency, it is unlikely that a practitioner would be able to translate, adapt and validate such an instrument.

Many humanitarian practitioners subsequently cross-reference a number of standard symptom checklists or structured questionnaires, based on general findings around psychosocial stress symptoms (these include the Impact of Events Scale – Revised (IES-R). Qualitative instruments such as focus group discussions or key informant interviews may be used to contextualise the symptom checklist. While these quantitative methods focus on the prevalence of psychosocial stress symptoms, they may also be useful in identifying local notions of distress. If assessment instruments are contextualised, results cannot be compared across cultures. As the assessment is framed in terms of psychosocial stress symptoms, humanitarian responses may include interventions that aim to address both social and psychological concerns. This may result in a diverse range of psychosocial and educational programmes, as well as integrated therapeutic programmes.

Cultural relativism lens

Those with a relativistic view of culture question the notion of a universal diagnostic system. They argue that transcultural diagnostic categories are invalid, as they often fail to capture the different meanings that people attach to events and their responses. For example, if someone experiences intrusive nightmares, is that a symptom of PTSD, or are malevolent supernatural forces trying to communicate with that individual? The answer is dependent on a person’s belief system. This approach aims to assess local understandings and perspectives of distress through qualitative or ‘thick’ descriptions. In comparison with the universal lens, this approach tends to argue that communities are more resilient to violence and displacement.

Within this assessment methodology, attention is focused on the way in which the local population understand and respond to their misfortune. As different cultures have different beliefs around personhood (i.e. ideas around ‘self’, the distinctions between mind and body) and human agency (i.e. the human capacity to make and impose choices on the world), the emphasis is on understanding people’s lived experience. The community’s subjective understanding of the situation and psychosocial distress provides an important foundation for informing subsequent humanitarian interventions. Rather than adopting a set proforma response, responses should be informed by the socio-cultural context. Typical humanitarian responses may focus on supporting community resources, re-establishing coping strategies and providing the opportunity to engage in traditional cultural practices.

With each lens, it is also important to look at what counts as the truth, and whose interpretations of reality are disqualified as anecdotal or unscientific.

A cultural relativism lens to assess psychosocial distress in Darfur

Violent conflict resumed in Western Darfur in 2003. Estimates of the official death toll currently range between 200,000 and 400,000, and 1.9 million people are thought to be internally displaced. We carried out a brief assessment of psychosocial distress among two IDP communities in West Darfur in September 2005. Using a culturally relativist approach, the aim was to understand how community members made sense of their suffering, expressed their distress and created meaning within the chaos of their lived reality. Using narrative interviews, this approach can provide a useful analytical lens through which to interpret more descriptive sources of data.

Methodology

The approach used open discussions in order to unearth the manner in which individuals and groups constructed their experiences of the world. This process aimed to increase understanding of participants’ past life experiences, and gather information about the meaning that people attached to events, and their responses. This was important in identifying local coping mechanisms and health management strategies. Our target group involved a cross-section of the adult displaced population; all the interviewees were from the Masaalit ethnic group, the predominant ethnic group in the camps.

Initial Focus Group Discussions (FGD) were used to identify key roles within the community. This involved 30 participants in total. Interviews were subsequently conducted with Sheikhs, traditional herbalist practitioners, Islamic faith healers, representatives from women’s health groups and local staff of NGO health clinics. This helped us to understand local socially sanctioned therapeutic models and health-seeking behaviour.

Face-to-face interviews were then carried out with randomly selected interviewees, involving between two and four participants at a time (60 people in total were interviewed). The aim was to gather information on ideas of distress or coping, by gentle probing (i.e. building on informants’ previous statements to formulate the next question), but without leading the responses. During the interview, phrases that directly related to ideas of distress or coping were recorded. Based on the context of the surrounding conversation, we also tried to extract specific meanings from each statement. By the end of each interview, we had collected a list of significant statements. We then organised these statements according to common themes. Some of the statements were fed back to the interviewees to check that we had rendered their experience correctly.

Insider view

Many of the participants recounted the impact of the displacement experience and how this affected their behaviour immediately afterwards. Some identified unusual behaviours, which they associated with the shock. However, they seldom attributed local expressions of persistent behavioural problems to exposure to an extremely stressful event, but rather to a neglect of social, transgenerational (across different generations of the family) or religious duties. People understood their distress in terms of the present situation, rather than past traumatic experiences. It was apparent that the current experience of displacement – rather than exposure to a violent event – was seen as more significant in explaining current distress. A standard symptom checklist may have indicated high levels of suffering in terms of symptoms suggestive of PTSD, resulting in humanitarian interventions focused on past psychological distress, rather than current social distress. As such, this may not have matched priorities of local populations.

Seeking help for medically unexplained bodily complaints (the physical experience of psychological distress) is common in all societies. However, the specific bodily symptoms will vary considerably across cultures. Respondents reported an increased prevalence of physical illness within their families since they arrived in the camps. These included vague aches and joint/back pains, headaches and feeling ‘out of sorts’. While there are a number of different ways to interpret ‘bodily distress’, it is thought to be prevalent in cultures that traditionally inhibit seeking help for emotional distress. Interviewees said that they normally did not like to talk about distressing experiences as doing so may ‘tempt fate’ and bring bad luck upon the family. For some, it is seen as a proxy indicator of distress. While the somatic expression of distress may be gauged thorough standard health assessments, it would not necessarily be picked up in a standard psychological checklist. This would support the view that health care data from health posts and clinics may provide a valuable source of cross-referencing.

It is unsurprising that, when interviewees talked about the effects of their past experiences on their present psychosocial well-being, the majority spoke about distress within the social body, rather than the individual body or self. Respondents talked about the effect that fleeing from their villages had had on the community’s social life, livelihoods and individual social functioning, rather than on individual psychological well-being. People talked readily about losing their dignity and identity, and the traditional roles they enjoyed in their village, such as owning land and animals and being able to care for their families. They also linked personal notions of distress to their external social domain, rather than to their inner psychological world. While most respondents identified the need for basic food, health, shelter and security, the majority expressed concern about how these needs were being met. Many spoke about the distress of losing ownership and control within emergency responses. This may suggest that emphasis should be placed on identifying and mainstreaming positive psychosocial outcomes across sectors, i.e. food, protection, security, shelter water and sanitation. This means addressing physical needs in a way that also explicitly gives attention to the social and psychological dimensions of people’s well-being. It may indicate a need to give beneficiaries more control over the process of receiving humanitarian assistance. It may also indicate a need to support community organisation and cultural activities.

Conclusion

Within the humanitarian sector, a number of instruments are used to assess levels of psychosocial distress among war-affected populations. Each draws on a different set of assumptions, and provides a different lens through which to view this distress. These differences affect how the ‘distress’ is understood, categorised and analysed. It also informs the type of humanitarian intervention that may be designed in response to the perceived psychosocial distress. Many quantitative assessment methodologies take the view of the outsider. A culturally relativistic approach, however, attempts to see things from the insider’s point of view, to understand the subjective ways in which people perceive and respond to violent conflict and displacement. This can provide a powerful tool with which to interpret more descriptive sources of data. Practitioners can then design interventions that are more appropriate for the specific local cultural context.

Angus Murray is Regional Conflict Policy Officer with Tearfund, and a psychotherapist within the Psychological Health Services department at Interhealth. His email address is angus.murray@tearfund.org.