The majority of the projects are financed by the Netherlands Ministry
of Foreign Affairs (Development Co-operation). TPO is the current name for the Institute for Psycho-social and Socio-Ecological Research Amsterdam (IPSER-Amsterdam),
which was founded in 1995.
The refugee issue
The number of refugees in the world is growing quickly - from 1.4 million refugees in 1960 to more than 20 million in 1997. In addition, there are now
more than 24 million displaced persons. These people are refugees within their own country.
The distribution of the world's refugees is not spread evenly throughout the world. Half of the world's displaced persons and one third of the world's
refugees live in Africa. Half of the world's refugees live in either the Middle East or in South Asia. Whatever their origins, their physical and mental suffering
can be extreme. They have experienced a war or a major disaster before making the decision to flee. The flight itself, often by foot over a long distance in
inhospitable environments and circumstances, is difficult, if not extremely hazardous. Almost always, the old social structures have collapsed, their families
ripped apart. Once in a refugee camp they encounter lack of comfort, security, safety, and exposure to disease.
Children
Children are not only passive victims of violence, they can also be forced to become fighting soldiers. They become witnesses to unimaginable atrocities.
Research on child refugees in Mozambique showed that 77 percent of the children had witnessed murder, moreover, 51 percent were abused or tortured. Many actually
saw their parents or other family members being killed. Large number of them had their own body parts - hands, noses, ears, and even genitalia - cut off.
In our own investigation among Sudanese children in North Uganda, we found that more than 90 percent of the children experienced loss of properties and
lack of food, 80 percent lost a family member, and about 60 percent witnessed the death of a family member, suffered from lack of water, poor health or no
medical aid. About one fourth of the children had been tortured or kidnapped. Obviously, these children develop serious mental traumas. Their complaints could
last for a few days or weeks, but, unless treated, are more likely to continue for months and years. Symptoms include immature behaviours for their age such as
incontinence, exaggerated dependence, nightmares, even repeated rocking motions with their bodies, and head-banging. They often refuse to eat, and have a variety
of psychosomatic complaints including headaches, dizziness, and stomach-aches. Older traumatised children often are exceptionally nervous, restless, and irritated.
Material aid is not sufficient.
Many refugees, adults and children alike, suffer from Post Traumatic Stress Syndrome (PTSS). They are fearful and easily panicked. They have nightmares
and day time flashbacks of distressing images. They become depressed and apathetic. Violence, as a way of releasing pressure, often occurs within their families and their communities. In countries with large groups of traumatised people, such as Cambodia, Ethiopia, and Mozambique, people's reduced ability to function can seriously limit the country's development.
In spite of all these problems, little attention has been paid to the mental health of refugees. A common thought is: "as long as they eat and have shelter, things will be okay". Such thinking reduces victims of war and disaster to individuals without a psyche, that is people who merely require material aid or who only experience physical problems. Moreover, the poor mental health of refugees is a threat to their quality of life and their life expectancy.
To TPO providing aid is more than providing food and shelter. Aid also is aimed toward restoring, and preventing further deterioration of the refugees mental health. In fact, TPO believes that providing only physical and material aid can bring refugees to helplessness and dependence, resulting in a loss of self-esteem which inhibits them from taking responsibility for their future. On the basis of years of experience with large groups of traumatised people from different cultures, TPO's experts have become convinced of the fact that attention to psychosocial problems is essential to empower people to continue their life and to contribute to the building of a new, more harmonious community.
The programme: local collaborators and local culture form the base.
Victims of atrocities are likely never to forget what has happened to them. However, it is possible to empower them to function again. Psychological help needs to be provided as early as possible in order to reduce the consequences of trauma, maintain self-esteem and prevent the re-traumatisation of already traumatised people.
Western therapeutic intervention which most commonly occurs by individual treatment, often with psychiatric medication, is not appropriate to refugees given their large numbers and the fact that they are for the most part from low-income countries.
In collaboration with experts from Africa, Asia, and Europe, TPO has developed an intervention programme for large numbers of traumatised people. The TPO programme adapts various methods of intervention for each situation and culture, but always tries to work with the community to help them solve their own psycho-social problems. By focusing on strengthening self-confidence, creating a more fulfilling life, and developing new social networks, refugees begin to gain confidence in their future. Collaboration with other aid organisations and local organisations is always essential to allow refugees access to existing services. Group activities, such as self-help groups for torture and rape survivors, are used to reduce post traumatic stress. Vocational skills training stimulates income generating activities and assists poor communities to achieve some independence.
Contents
The TPO programme starts with the assessment of the psycho-social problems. We have found that problems are diverse. In one refugee camp for example, the biggest problem can be recovering from rape. Elsewhere, the largest difficulty may be working with violent or uncooperative children who act out as a result of being traumatised. In some countries, HIV-counselling is an important issue. Once the local sets of problems are defined, methods are devised to intervene, usually by combining western ideas with local and traditional ways of dealing with emotional difficulties.
To be successful in the implementation of intervention strategies, a core group of local health workers, teachers, traditional healers, community leaders, etc., is trained by local and international specialists from TPO. They teach core group participants how to recognise mental illness and how to use appropriate therapeutic techniques.
Research
Understanding and treating collective trauma is a new field. Consequently, scientific research plays a key role in TPO's activities. One important topic of research is the identification of "local idioms of distress," that is the local language people use to express their mental or physical problems. Another research effort attempts to understand each culture's local methods of helping traumatised people, and to find ways to work within the local system of care. Evaluation and action research is also important to TPO. This research elucidates how an intervention in one situation, might be modified to be of use in another. Evaluative research also supplies information that is needed to refine, adapt, and improve our programs. The research also contributes to the development of a multi-site human rights database.
The basic principles are:
The TPO-programme is based on different disciplines: public mental health, psychology, psychiatry, anthropology, psychotherapy and epidemiology.
The programme is based on the following principles:
· The psychosocial and mental health problems of refugees can be recognised
and treated and it is possible to prevent aggravation of problems.
· The most effective way to implement interventions is through methods
that are accepted in the local culture.
· Collaboration with communities is necessary.
· If possible, local professionals and health workers need to be employed.
· Programs should be from 5 to 6 years duration, in order to adequately
train a local core group to continue the programme without, or with only
sporadic assistance, from TPO.
· Knowledge- and skills training are considered as essential parts of the
programme.
· Culture-specific interventions and prevention are central to the
programme.
· Research is necessary for a successful programme.
· Ethnocentrism should be avoided.
For whom?
The TPO-programme is meant for refugees and other groups of people who have been traumatised by war, human rights violations, or other forms of organised
violence.
TPO works either in refugee camps or in communities that have been affected by organised violence.
Requests for help are usually made by governments and aid organisations. In such a case, TPO gives advice, training materials, and, if necessary,
provides experts who help in setting-up the programme and in training a core group of local experts.
Where does TPO work?
North Uganda
In 1994, TPO started a project to provide psycho-social help to 230,000 Sudanese refugees living in the West Nile-area. Focus groups and interviews with key people
were organised to gain a deeper understanding of their problems. This resulted in a long list of problems, such as overpopulation, poor sanitation, high infant
mortality, domestic violence, inadequate food rations, alcohol abuse, and criminality. Significantly, they also mentioned repeatedly how difficult it was to cope with their
past traumatic experiences.
A TPO anthropologist talked with local healers to understand how these problems were locally expressed and traditionally treated. Particular attention was paid
to the role of rituals in helping people. This information was then used to help develop culturally appropriate interventions and training materials.
Eighteen candidates with a prerequisite education were selected to participate in a Training of Trainers course in counselling, given by the expatriate staff.
The contents of the training and training materials were based on the WHO/UNHCR book Mental Health of Refugees. Adapted modules were added to fit the northern Ugandan
cultural context. After the course the participants continued to receive supervision by TPO's expatriate staff.
After six months of work under TPO supervision, six of the eighteen local trainees were selected to become trainers or counsellors. After receiving additional education,
they began training psychiatric nurses, medical assistants, teachers, pastoral workers, and local healers. In addition, the whole group of trainees continued
to make home visits in the camps and to assess psycho-social problems. They tailored interventions to meet specific needs. Some refugees took part in counselling
groups to talk about traumatic events, others were involved with self-help groups so they could learn how to give and receive support to rebuild the community.
Seminars were being organised to train camp leaders, their assistants and health care workers who engage in medical care or income generating activities.
Even though the project mostly deals with psycho-social problems, people with severe mental illnesses also report for treatment.
Health workers, therefore, are provided with a training followed by a supervision in identifying and treating severe mental illnesses. For
psycho-social problems there is a special infrastructure within the project. This includes counselling rooms in all the camps. For the treatment of the
severe mentally ill there is a co-operation with the existing primary health care facilities.
Cambodia
Prior to the civil war, the Cambodian population was exposed to carpet bombing, followed by the lengthy civil war. Three million people died,
which is more than twenty percent of the country's population. Since the civil war has receded in scope, nearly 300,000 people returned from the Thai
border-camps to the regions where they were born and raised. Throughout these ordeals, almost all Cambodians suffered severe trauma. However, until
recently there has been no mental health care in the country.
TPO believed that before appropriate aid could be provided in Cambodia, an assessment, in the context of the local cultures, had to be carried out.
Accordingly, in addition to demographic information and assessing the standard
Western types of psychological symptomatology, narrative interviews with people
from different sections of the population were obtained, in order to understand
the local idioms of distress and to know about the specific forms of help-seeking
behaviour, social networks, coping styles and EMS explanatory models.
Then, an investigation was made to document the existing local health facilities
in each village, district, and province. The information revealed that the
traditional healers were able to focus on crises, such as marital problems
or community conflicts, but did not pretend to be able to treat all the mental
health problems. As was the case in Uganda, thousands of people with severe mental
illness and epilepsy asked for help. On the basis of this information, teaching
ideas were formulated and training materials developed. For example, TPO developed
a model which provided these people with treatment and after care in the village,
district or at the provincial level.
Criteria were also developed to select trainees who were trained by the
core group to work in the community.
The core group members received eight months of training by the TPO expatriate
professional staff. They also learned to work with the local healers, which
helped the core group to become accepted by the community. One of the most employed
intervention technique was the development of self-help groups in the villages.
For many of the participants this was the first time they ever discussed their
experiences.
HOW TO ORDER OUR DOCUMENTARIES
In co-operation with Jan van den Berg TPO is making a series of documentaries.
The documentary on Cambodia "MINDFIELDS" and the documentary on Sudan "WARGAMES" are available
and can be ordered by transferring
US$ 15.- on TPO's bank account 42.55.88.866 Please state clearly which documentary
you wish to receive.
Board TPO
H. Kosterman, LL.M., chairperson
G.J. Doornkate, M.Sc., secretary/treasurer
Prof. R. Giel, M.D. Ph.D.
Prof. Y.N. Wolffers, M.D. Ph.D.
Staff TPO
Prof. Joop de Jong, M.D., Ph.D., director
Lenie Huisman, office manager
Ivan Komproe, Ph.D., methodologist/statistician
Miranda Mion, M.A., secretary
Diana van den Driesche, M.A., researcher
Astrid Kamperman, M.A., researcher
Project directors/Counterparts
Cambodia
Willem van de Put
Ethiopia
Mesfin Araya
Gaza
Eyad El-Sarraj
India
Eva Ketzer/Antonella Crescenzi
Nepal
Bhogendra Sharma
N.-Uganda
Nancy Baron/Patrick Onyango
S.-Uganda
Marjolein van Duijl
Mozambique
Adão Marcos /Custódia Mandlhate
Democratic Republic Congo
Jaak Le Roy
We are greatly indebted to Gert Hagen, Wim Verboven and Inger Ott for
their assistance in producing this text.
Nepal
Center for the Victims of Torture & TPO
Target group: Lotsampa's 90.000
Nepalese victims of torture 10.000
Tibetans 30.000
Staff: 17
India
Tibetan Mental Health and Psychosocial Programme
Target group: Tibetan community in India 200.000
Staff: 6
Cambodia
TPO Community Mental Health Programme
Target group: Cambodians in 3 provinces 3 million
Staff: 22
Democratic Rupublic Congo
Therapy choice in Kinshasa
Target group: inhabitants Kinshasa 200.000
Staff: 5
North-Uganda
Psychosocial help to Sudanese refugees in Uganda
Target group: Sudanese refugees 230.000
Staff: 28
South-Uganda
University of Mbarara and TPO
Target group: Ugandans 200.000
Staff: 15
Ethiopia
TPO/AAU Mental Health Programme
Target group: Eritreians 450.000
Sudanese/Somali 400.000
Staff: 54
Gaza
GCMPH & TPO
Target group: population GAZA 1.000.000
Staff: 20
Mozambique
Target group: population Boane 600.000
Staff: 4
The Netherlands
TPO
Research on migrants and refugees.
Pilot:
Bosnia
Sri Lanka
Tanzania
Total target group: 6.500.00
Total TPO collaborators : 176
Recently pilot projects have started in:
Algeria and Namibia
Publication list November 1995-1997
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