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DEVELOPING CULTURALLY RELEVANT INTERVENTION PLAN FOR PSYCHOLOGICAL TRAUMA: AN APPLICATION OF COMMUNITY BASED PARTICIPATORY RESEARCH APPROACH FOR MENTAL HEALTH.

Byline: Salma Siddiqui and Rashid Qayyum

ABSTRACT

Objective: To develop culturally relevant intervention plan for psychological trauma using community based participatory research approach in times of crisis.

Study Design: Qualitative study.

Place and Duration of Study: Army Public School (APS) Peshawar, from Dec 2014 to May 2015.

Material and Methods: The participants included 35 teachers, 60 parents and 5 administrative staff of the Army Public School (APS), Peshawar Pakistan, who participated in the consultative group meetings over a period of 6 months starting from a week after the APS attack on December 16th, 2014. The participants through a collaborative process identified the community needs, priorities and resources. The goal was to generate realistic intervention plan which can be implemented and widely accepted by the community. Data, based on the discussions in group meetings were transcribed and analyzed for themes and developing intervention plan. Results: The participatory research approach with the community helped design the culturally sensitive intervention plan for the trauma stabilization of the affected community.

The study design was helpful in addressing the needs assessed; restoring sense of safety, respecting the emotional needs as per cultural norms and helping the community reconnect and resume normal functioning.

Conclusion: The study highlights the importance of adopting a culturally sensitive approach and including community in designing and delivering the intervention for psychological trauma.

Keywords: Community Based Participatory Research (CBPR), Mental health, Psychological trauma, School Attack.

INTRODUCTION

We are living in the time where trauma has acquired saliency as every day we hear individuals and communities unexpectedly caught in the acts of terror. The impact of psychological trauma varies from person to person depending on the traumatic event and the personal resourcefulness. The clinical literature defines psychological trauma as "an affliction of the powerless" which results in the feelings of utmost helplessness, often exhibited by behavioral and emotional symptoms1. As most of the work in this regard has taken place in the West, our understanding of trauma, its ramifications and management is dominated by western point of view2.

There is critique, however, of this approach for instance; researchers have reviewed the undesirable and unforeseen consequences of using western concepts throughout South East Asia and argued that explaining psychological distress and trauma from astern perspective which is predominantly biomedical reasoning of human afflictions-excludes explanations of distress at culturally relevant context3. This universalist approach also undermines the inherent resilience in a community which may be instrumental in managing the trauma with greater endurance4.

Though, Pakistan has been at the receiving end of trauma for many decades, the attack on Army Public School (APS) in Peshawar, on 16th December shocked the entire nation because of the brutality of the attack on the adolescent students. After this terrorist attack on APS the afore mentioned concern was considered significant because of two reasons: first that the impact of trauma was unprecedented and second, there was insufficient psychosocial support structure and process in place to manage the psychological trauma in accordance with the local norms and culture. This vacuum attracted many well intentioned mental health experts from the developed world to contribute in psychological assessment and to provide interventions to the victims.

The mental health team designated with the responsibility of managing the impact of trauma was cognizant of the attributes and sensitivities of local predominantly Pasthun as well as Hindko culture of KPK where, code of honour of self-restraint and pride is exhibited even during the times of trauma and extreme distress. Moreover, the religious mourning practices are strictly adhered to and often expression of grief to outsiders is not approved of. Men are considered chivalrous and the women display great fortitude even in the face of such abhorrent tragedies5.

Keeping this in consideration, a participatory research approach was undertaken to assess and manage the trauma by involving the community, being mindful of their cultural norms of grieving. The community based participatory research (CBPR) is regarded as an alternative research paradigm, which integrates psychological intervention and social action to improve health related behaviors6. Instead of being simply an outreach strategy for community, CBPR represent a systematic effort to include community participation in decision making and include local norms and practices in to the research domain7. The aim, therefore, was to rely on the community members in constructing knowledge about issues being faced and derive solutions to manage the impact of trauma through interventions which respect the local culture and are context specific8.

It, thus, strived to reduce the exclusive authority of experts and enable the affected people in not only articulating their issues but also how they desired these to be addressed7.

MATERIAL AND METHODS

The participants of the study included 35 teachers, 60 parents and 5 administrative staff of the Army Public School (APS), Peshawar. The study was based on participatory research method approach to meet the objective of designing the psychosocial intervention plan for the management of psychological trauma after the tragic school attack. The project continued for 6 months and the authors held group discussions with the participants at least once a week to assess their emotional state, identify needs and priorities. The mental health team provided psychosocial support to the participants and using evidence based knowledge facilitated the discussions to design culturally relevant community based intervention plan. The note taking were done by an independent member, these were later transcribed and shared with the participants to check the accuracy and reliability. The researcher and the mental health team engaged in reflective process after each group discussions.

The goals as well as interventions were based on the reflective process and the group discussions.

Study Design

This was a qualitative study with multi phased community based participatory research (CBPR) approach where collaboration and partnership of stake holders were the key element. Each phase had separate goals and objective to meet the overarching goal of providing the psychosocial support to the community to resume the normal activities of life after experiencing the psychological trauma.

Setting

A community study set in the cantonment area of peshawar city, where the school was situated.

Participants

Participants included teachers (n=35), parents (n=60) and administrative staff (n=5) of the school who suffered themselves or lost a member of the family or colleague in the brutal attack on the school. Other community stakeholders, i.e. the school and army administration and mental health team also participated. As the research requires a democratic social context allowing the participatory spirit, effort was made to build rapport and engage the participantsin the discussion to voice their concern and needs.

RESULTS

The note taking done during the group meetings were analysed for their common themes and gaps were identified which were further focused in next group meetings with participants. Each group meeting was followed by a reflective session between the researcher and the mental health team to gain insight into the verbatim.

Table: Themes that emerged from the group discussions and the intervention goals.

Themes###Goals for intervention

Sense of insecurity and fear###Restoring sense of safety through providing them

###safe space to talk about their distress.

Need to mourn and grieve according to their###Facilitating grieving and mourning in communal

cultural/religious norms###meetings according to the cultural and religious

###norms

Need for a separate place-away from###Provision of psychosocial support by establishing a

hospital setting- to access psychosocial care.###center at a physically convenient place

Reconnection with everyday life###Facilitating the grief work and resumption of sense of

###control by becoming part of decision making i.e.

###consultation for the date of reopening of the school

###and reconstruction of school building.

The emerging themes were shared with the participnts to arrive at the intervention plan.

As the project initiated in response to the need to assess psychological trauma and provide psychosocial rehabilitation after the tragic attack on APS, the first step was to engage all the stake holders in the process. Using CPBR approach with multiple consensus building meetings, the team worked together to identify the needs, priorities and resources and develop a strategy to address the needs. The goal was to generate a realistic intervention plan which can be implemented and widely accepted by the community. In this project, the researcher brought to the group evidence based understanding of trauma responses, which has been found helpful in other communities, whereas, community members shared their lived experiences and insights that only someone dealing with such trauma can know and understand. These experiences and insights led to ensure further administrative facilitation to arrive at intervention plan acceptable to community.

The administrative partners brought their understanding to realize the plan in accordance with the security and other concerns. The initial phase was to engage with the participants and give them opportunity to express their anger, frustration and grief over the incident. The group discussions not only helped in fostering resilience through community support, it also provided an opportunity to identify the signs of distress which needed immediate psychological/ psychiatric management. There were many apprehensions and concerns expressedin the initial meetings i.e. a prevalent sense of insecurity, fears of second attack and demoralization on security lapse. The participants were listened to, informed and facilitated to help reduce their distress. The goals that emerged from group discussions were of establishing sense of safety, rehabilitation and reconnection.

The CBPR emphasizes the observation and reflective practice in planning and management of psychological trauma and its associated distress, therefore, each step was an outcome of consultative process using participative approach which helped design intervention plan for the community.

Intervention Process

The intervention in the community was an outcome of the collaborative process with following objectives:

* Engagement and participation of all stakeholders

* Arriving at context based understanding of distress and developing culturally sensitive trauma intervention plan to meet the expressed need.

The themes presented in the table were the guidelines for the three phases of intervention.

DISCUSSION

The traumatic incident on 16th Dec 2014 was a huge trauma both for the people of Peshawar and the country. Dealing with a psychological trauma of this magnitude brings to the fore the critical question with regards to ethics of practice and research. There were two ways to deal with this psychological trauma. First, to rely on the universal understanding of trauma and its associated distress, and move forward to explain and manage the distress using interventions used elsewhere. Second, making a reflective inquiry and acknowledging the limitation of delivering uniform trauma management plans which is sensitive to the local norms. This is a critical place requiring both ethical and cultural sensitivity. There is comfort in simplifying the context and reducing it to yet another trauma situation, identifying the resultant distress aspost traumatic stress disorder (PTSD) and intervene with empirically supported the rapeutic intervention plans.

However, such an approach assumes universality of distresse xperiences and ignores the cultural, psychosocial, organizational and political realities of a context. We tend to see people and communities suffering, showing signs of PTSD and become blind to their ways of coping. Recently, researchers have highlighted the need to look at the definition of traumatic response i.e. PTSD9,10 as many communities have demonstrated resilience despite suffering tragic conditions11,12. Therefore, it was pertinent that participatory method is adopted both in understanding and assessing the needs of the community after the tragic incident and the intervention plan should be designed collaboratively. This was important as people of Peshawar both Pashtuns and Hindko speaking communities are known for their pride in their custom and values and refrain from making a public display of their grief.

The team responsible for designing and delivering the intervention, therefore, with the orientation of participatory research method, engaged all the stake holders in the process at each step with the goals of establishing sense of safety, rehabilitation and reconnection.

The participatory process entailing the trauma intervention plan could be described in 3 phases of intervention based on the themes presented in table.

1st Phase: Reaching Out and Engagement

Just after the tragedy, there was chaos, community's sense of safety wasshaken, and there were rumors and mis-information, further worsening the sense of safety. The female teachers had not met with each other for some time after the school attack as they were in grief and were in mourning for their own loss. The first meeting to initiate the participatory process was the hardest part for the teachers and parents to meet each other after the tragic day as they collectively relived the tragedy. However, crying, hugging each other and supporting with silence and words were helping them as they acknowledged with the researcher before parting. Initial meetings just provided an opportunity to engage and establish contact with fellow community members. This was established as a safe space where teachers and parents could vent out their anger, disappointment and share their grief with each other. They were listened toand provided informational care to reduce their sense of insecurity and fear.

They lingered on after the meeting, talking to each other or with the mental health team to describe and share what they were going through. The sharing was a therapeutic experience for most of the participants-as evidenced elsewhere as well 13 and those who required specific professional intervention were referred to the experts. In later meetings they were helped to practice mindfulness based exercises to lower their distress.

2nd Phase: Mourning and Grief Work

The participatory approach helped identify not only the signs of distress but also the community practices employed in dealing with such tragedies. The professional support was made available but primarily the community was facilitated in following their cultural and religious practices in dealing with grief. The intervention was tailored to the context instead of administering it as the only intervention method, in accordance with the spirit of community resilience14.15. The community exhibited immense resolve and demonstrated fortitude through adversity. They were grieving and shaken but not broken. It was observed that they reconstructed meaning in their life through their faith; they would recite specific verses from Quran where martyred are promised better recompense for their trial and loss. They sought solace in faith and reminded themselves and others how only those chosen ones are tested through such trials and those who show patience are rewarded in the hereafter.

The cultural narrative of grief and mourning was dominant in this phase.

3rd Phase: Reconnection, the School Reopens

The return to school was a critical question. If the school remained closed for a longer duration it would have reinforced the sense of insecurity and helplessness in the community; on the other hand if the school resumed and parents felt anxious to send the children back to school, it would have further exacer bated their sense of loss and demoralization. It was important to determine whether parents and teachers are psychologically ready to send the children to school. The participatory method was already in practice so it provided an opportunity to engage the parents and teachers in this decision making. An indicator of the efficacy of participatory methodology reflected in the fact that parent and teachers in their separate meetings reached similar conclusions that school should be reopened as soon as possible to bring back normalcy and therefore the date for opening the school on 12th Jan 2015 was agreed on. This was the first step towards reconnection and normalization.

The participants also reached an agreement as to what the activities should be on the first day of the school and the following weeks. The psychosocial needs of the students took priority16 and activities were designed to provide space to students to express their grief through art activities, letter writing, sports and other co-curricular activities. The teachers understood the role of emotional care in adolescents after trauma, and how students who are listened to and given opportunity to share each other's stories, actually heal and overcome trauma7,17.

The curriculum and teachers' role in handling the emotional stress of students was also the focus. Teachers were supported in sharing their emotional burden and provided training before reopening of the school and afterwards as well. They had access to mental health team who were present both on site (APS) and at the psychosocial center to facilitate students and teachers in managing distressing symptoms.

It is important to mention here that the mental health team did not set out the objective to conduct this project as a research; instead the objective was to develop and administer a culturally relevant intervention plan to manage the psychological trauma. The author asa researcher brought this perspective to the project. It was reassuring to learn that strategies adopted to deal with the trauma in a culture sensitive manner by adopting a participatory approach resonated with the esteemed work by Herman18, who argued for stage based intervention strategies. The three stages resulting from consultative process were validated by her writings. There were, however, many challenges faced by the team during the project which the researcher and mental health team dealt with in adherence to the cardinal principles of ethical practice.

The CBPR in the mental health area is relatively new19 but given the emerging mental health need due to migration and political conflict, many researchers and practitioners are realizing the need of such an approach20. In Pakistan such an approach has not been documented in the mental health domain yet. After 2005 earth quake and 2010 floods the psychological rehabilitation focused on providing psychological care in the traditional model, where individual's distress and pathology was focused similar to his physical health need21-23. The scale of the APS school attack necessitated that a participative approach with communication of respect to the local values and custom is adoptedto start the process of healing24. Designing a psychosocial intervention plan for a community to deal with trauma following participatory research method requires collaborative relationship with those for whom intervention is being designed or delivered.

In this sense the process develops out of convergence between science and practice; the aim of science is to pursue scientific inquiry and of practice is to deliver culturally relevant community led intervention plan to deal with the distress community is facing7. The researchers acknowledge that methodologically the study has many gaps, but it is known that in times of crises the service takes precedence over research25. Nevertheless, this study has highlighted the need to include community in decision making along with the importance of developing culturally sensitive and relevant psychological intervention plans.

CONCLUSION

The participatory methodology was helpful in designing the intervention plan to deal with the impact of psychological trauma after the school attack. The participation of community in each stage led to culturally sensitive trauma management approach which is supported by the recent theoretical insight as well18. The present study using the CBPR orientation emphasizes the importance of using culturally sensitive and context specific approach in trauma management.

ACKNOWLEDGEMENT

The authors acknowledge the support of mental health team and Pakistan Army Administration in facilitating the process of developing a culturally sensitive psychological intervention plan for trauma management.

CONFLICT OF INTEREST

This study has no conflict of interest to declare by any author.

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Publication:Pakistan Armed Forces Medical Journal
Geographic Code:9PAKI
Date:Oct 31, 2017
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