4 years 4 months


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Finally, after 4 years 4 months, the time has come for me to close this circle and move on for the new one. I am very content to have my work successfully completed and I am looking forward for my new mission from next month.

Even before I joined ICRC, I was aware about the issue of disappearance in Nepal and the psychosocial aspects related to the families of the missing. In 2009, I had worked in a research project related to Missing persons and their families in Surkhet and I wrote about it on the occasion of Day of the Disappeared in 2010.

In 2012, when I joined ICRC, the pilot phase was coming to closure, and the first and second expansions were already rolling on. I worked for the first expansion districts covering three districts of Kathmandu Valley.

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At the same time, we were also preparing for the launch of third expansion in 10 districts, I was engaged in assessment and the implementation of program in Dhading and Nuwakot in partnership with Nepal Red Cross Society district chapters.

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In 2014, we finally rolled out the final/fourth expansion of the program, I was managing the program in Kavre, Sindhupalchwok and Ramechhap. I wrote about my experience after two years here.

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After earthquakes in 2015, our team were engaged for psychological first aid response in affected districts both by training Red Cross Volunteers as well as providing services in the community.

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In 2015, I was supported for my participation in 11th Mental Health in Complex Emergencies (MHCE) course, organized by Institute of International Humanitarian Affairs (IIHA), Fordham University in Addis Ababa, Ethiopia. Thanks to ICRC for that support.

Finally, this year, we have completed the program successfully and produced the dissemination materials. And at the last moment, we also had an opportunity to provide an brief orientation on psychosocial support for the staff of Commission of Investigation on Enforced Disappeared Persons of Nepal and we are hopeful they will consider the importance of psychosocial aspects while helping the families of the missing in their future work.

I would like to dedicate this photo book to my ICRC colleagues and working team (NRCS district focal persons, accompaniers, and program supervisors): ICRC-photo-memoirs.compressed and also would like to thank them all for their support and cooperation.

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Mental Health in Complex Emergencies 2015 Course


Some months ago, I  participated in 11th Mental Health in Complex Emergencies (MHCE) course, organized by Institute of International Humanitarian Affairs (IIHA), Fordham University in collaboration with HealthNetTPO, UNHCR, and International Medical Corps at Addis Ababa, Ethiopia held from 20th to 30th September. 25 professionals from various countries representing/working in different international humanitarian organizations participated in the course. Me and one of my colleagues working in the psychosocial support program (Hateymalo) for the families of missing in Nepal was supported by ICRC to attend this course, thanks to my institution.

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About the course

The course was directed by Larry Hollingworth, C.B.E., Humanitarian Programs Director, Center for International Humanitarian Cooperation (CIHC); Lynne Jones, O.B.E. FRCPsych., Ph.D., Visiting scientist, FXB Center for Health & Human Rights, Harvard University; and Peter Ventevogel, M.D. Senior Mental Health Officer, United Nations High Commissioner for Refugees (UNHCR).

On the first week for Module 1, Larry Hollingworth, Peter Ventevogel, Lynne Jones, Catherine Evans and Inka Weissbecker facilitated various sessions covering the most essential topics on mental health and psychosocial support (MHPSS) in complex emergencies.

In the second week for Module 2, there were additional instructors such as Judith Bass and Charlotte Hanlon for topic on Conducting MHPSS Research in humanitarian settings, Lena Verdeli for topic on Group Interpersonal Therapy for humanitarian settings and Professor Atalay Alem for special guest lecture on Mental Health in Ethiopia.

Personal Reflection of Practitioners

I would like to share some short video clips of personal experiences and reflection shared by field practitioners about implementing MHPSS programmes in complex emergencies. Thanks to Kasey Cruz for helping to record my presentation, rest of the videos were recorded by myself. Thanks to Bishnu for the picture and Caitlin for writing her experience of the course.

 

Sujen Man Maharjan from ICRC, Nepal

Tadu Bezu from IMC, Ethiopia

Mahmuda from UNHCR, Bangladesh

Abdulwasi Yusuf from IMC, Ethiopia

Alaa’Alddin Al’masri and Awwad Manar from IMC, Jordan

Boniface Duku from HealthNet TPO, South Sudan

Caitlin Cockcroft from UK working in HealthNet TPO, South Sudan.

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 Being able to work with community resources, current resiliency and encouraging individuals to utilise their support networks already in place – this is something that will be the focus of all my work in future. We spend too much of our time focusing on people’s weaknesses, the problems and challenges they face, and how we can parachute in, provide and leave. I like that the conversation is changing especially with regards to mental health. We can’t be the savior who comes and treats and leaves. Much of the work can be done at the ground level, within the community. We can prevent mental health issues from developing or worsening by ensuring that people have, and use, their community support systems.

To read the complete text, please click here: IMC – MHCE- Caitlinwrites

#NepalQuake Mental Health and Psychosocial Support (MHPSS) Response


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Many compassionate people around the world have been touched by this disaster and suffering. They are starting to provide help in many ways. There are also initiatives being taken for mental health and psychosocial support response.

MHPSS.NET has opened up Nepal 2015 Earthquake Response Group  to share resources and information about the MHPSS response to the 25 April Disaster. If you are involved in the response or would like to contribute to resources, please join http://mhpss.net/groups/current-mhpss-emergency-responses/nepal-2015-earthquake-response/ Thanks to Ananda Galappatti (Sri Lanka), from The Good Practice Group and Wietse A. Tol for taking lead to organize and contributing valuable resources in this group.

HeartMind International in collaboration with TPO Nepal is preparing the response for both the short-term and long-term consequences of the earthquake on psychosocial well-being and mental health. They have made an appeal for donation for this effort: http://heartmindinternational.org/earthquake_response.html Dr. Brandon Kohrt have worked in Nepal for over a decade now and he is going to lead the response in order to ensure providing culturally appropriate and sustainable psychosocial services and interventions to earthquake affected families and children.

Several crowd funding have started online to support MHPSS activites in coming days.

Nepal Earthquake Relief Fund, Scotland UK: https://www.indiegogo.com/projects/nepal-earthquake-relief-fund-scotland-uk has been created by Claudia van Zuiden, solution-focused practitioner who have worked in Nepal before.

Disaster Relief and Psychological First Aid Near the Epicenter: https://www.indiegogo.com/projects/kopila-nepal-earthquake-response–2 has been created by Bonnie Walker on behalf of Kopila Nepal.

Nepal Red Cross Society have mobilized 12 PFA volunteers in Kathmandu valley from today and plans to extend this service with more volunteers in other districts as well.

TPO Nepal has started its work in Sindhupalchowk from today, Dristy Gurung, a friend shared in her facebook status.

Mental Hospital, Lagankhel is organizing mobile clinic around the valley for the services.

Some information can be obtained at: http://www.humanitarianresponse.info/en/operations/nepal/protection and can be learned how different humanitarian actors and organizations are supporting at this time.

Conversation about study on Spirit Possession in Sindhupalchowk, Nepal


Following text is the transcript of the conversation on his recently published paper titled, ‘A Village Possessed by “Witches”: A Mixed-Methods Case–Control Study of Possession and Common Mental Disorders in Rural Nepal’ published in Culture, Medicine, and Psychiatry Dec. 2014, Vol. 38, Issue 4, pp 642-668. Full text: Sapkota et al, 2014-A Village Possessed by Witches

I would like to thank him for his contribution to prepare this material.


Sujen Man (SM): What got you interested in exploring this ‘spirit possession’ phenomenon?

RP Sapkota (RP): In 2003, after my graduation in psychology, I started working for Centre for Victims of Torture (CVICT), Nepal. At that time, CVICT received a request from a high school in Kavre district to do an assessment of 12 children who had experienced fainting spells. My seniors (Dr. Bidur Osti, Dr. Wiestse Tol, Sushma Regmi, and Jamuna Maharjan) invited me to accompany them for the assessment and intervention program. We did a qualitative evaluation of the situation through individual as well as group interviews with affected children, parents, community members, teachers and traditional healers. At the end, we provided mass psycho-education involving community people, school children, parents, and schoolteachers. During our assessment and intervention, some of the children fainted. It was, at first, a very bizarre experience for me but got me fascinated. After coming back from the school, I began collecting data on the issue from various sources such as newspapers, NGO reports, and field visits whenever possible. By the end of 2010, I was able to collect data from 49 such incidents affecting more than 700 children (in seven years period since 2003). I wanted to understand why mass trance and possession phenomenon (also known as mass hysteria, mass conversion, mass psychogenic illness) was so prevalent or occurring in an epidemic scale in Nepal.

SM: I am curious how did you select the research site and sample for your study?

RP: Well, I was working for CVICT when we first heard about the possession incident in Sindhupalchowk. During one of the refresher trainings for counselors, one counselor working for one NGO in Sindhupalchowk showed a video of a possession incident in the village. After that again, I became aware about the mass possession incident in the village from one of my colleagues who was coordinating the training for CVICT at that time. For me this was an opportunity. So, I talked with some of my colleagues at CVICT, they were also interested to be involved in the study. Therefore, we communicated with the counselor from Sindhupalchowk and in his coordination and support we got access to that village. In our first visit, we met with two schoolteachers, a priest, affected people and their family members. Then, based on our inclusion and exclusion criteria, these schoolteachers and the counselor identified participants for the study.

SM: How did the people, esp. participants, receive the research team? What was their response? Were they willing to participate in the study or it took some time??

RP: As we have mentioned in the paper, people in this village were suffering for more than six months when we first visited the village. They had tried everything within their access (traditional healing to biomedicine) but nothing availed. They had spent lots of money. Furthermore, because this illness was affecting many people, social ecology was affected and social cohesiveness was decreasing. Enmity among the relatives and neighbors had increased. Therefore, they were willing to try anything that they thought might help them get rid of the problem in the village. I found them to be very friendly and supportive from the very beginning.

SM: There is a narrative of index case of Shakshi in your paper, which led to the possession epidemic in the village. Did this case solely led to such possession or had it been occurring previously as well. Interesting, you mention 30 people were affected in a single year following an index case.

RP: We talk about this issue briefly also in the paper that possession as such was not a new phenomenon in the village because there were many incidents when people of that village had experienced possession but they were isolated cases of possession of individuals. This was the first time that as many as 30 people were possessed. We have discussed about the possible psychosocial pathways of contagion in the discussion section of the paper but there could be many other pathways that we have not covered.

SM: You have used even video recording of possession episodes as means of data collection. It must have been great for data triangulation. Would you like to say more about this and how useful it was? Are possession episodes predictable which made it possible to video record it? I would like to know how was the research team able to capture it?

RP: Yes, having a video about possession episodes and also people talk about them really makes it feel like as if it is happening right now. We could observe expressions/behaviors of people possessed and the reactions of their family members and other bystanders as many times as we like. We could observe change in the behavior or indifference of the possessed person based on the reactions by the family members and others. Likewise, had it not been video recorded, we would not be able to see the participants make fun about what they themselves did when they were possessed during the interviews. If we had only audiotaped the focus group interviews then perhaps we would hear the participant laugh on and off but we would not be able to comprehend the intricacies involved. We wanted to video record the interviews because we hypothesized that those woman will be possessed during these interviews/discussions and we wanted to capture that apart from capturing what they had to say.

SM: ‘Excluded were women who reportedly were afflicted by a boksi but had not experienced chhopne…’ from sample and methodology section. Could you please explain more about this? What is the difference between being afflicted and being possessed?

RP: Anyone could be afflicted by witchcraft (Nepali: jaslāi pani boksi lāgna sakchha) but not all who are afflicted by boksi get possessed. They might have different ailments because of witchcraft but they won’t be possessed. Meaning, their “self” would not be controlled by some spirit.

SM: You mention about cases of 2 children as well who experienced possession which is not included in your study however. What could have been the reason behind – the imitation/suggestibility or the traumatic exposures in the school/home/community?? I recently heard about the case of child who had this problem after he was severely beaten by a school teacher and he had possessions several times in the school after that so, his parents had to change the school for him due to it.

RP: I cannot really say anything concrete on this but make some assumptions. As we have said in the paper, possession cannot be mapped into a single causal factor. There could be multiple factors at play. One of the assumptions could be as follows:

Psychologically speaking, possession is a dissociative phenomena and the literature in dissociation suggests that some people have 1) higher propensity to dissociate, 2) higher level of suggestibility, 3) higher level of fantasy proneness etc. They have the quality required to dissociate. People in Nepal, especially living in rural communities, are exposed to the idea of spirit affliction (for example lāgu/ lāgo lāgnu, bhoot/pret lāgne), spirit possession (for example devi/deutā chadnu/utrinu) through observing their parents, neighbors or through stories. They have the cultural knowledge that the spirits could possess a person. So, when they have problems that cannot be communicated directly and/or requires the attention of the family, school or the community then, for some people, the quality to dissociate and the culture knowledge of spirit possession come for a rescue in the form of possession; they get possessed.

SM: upon sharing the results, you write ‘None of the possessed women, their family members, or focus groups participants spontaneously associated the condition with traumatic experiences or other life stressors; nor did they view it as a mental health problem. Indeed, when the results of this study were presented to the community, they refused to accept the finding that possessed women had a higher risk of common mental disorders compared to the non-possessed women. They also did not see possession as a way of coping. Instead, they reaffirmed their view that spirits that were angry or upset had the ability to inflict harm by possessing people.’ How did the research team react to this?

RP: This made us realize that what we were saying was from our academic knowledge (etic perspective) and what they were saying was based on their experience and cultural knowledge (emic perspective). Therefore, during psycho-education we presented the psychological perspective as an alternative way of understanding what was going on in their village but not as a scientific fact.

SM: Did you explore about how religion conversion helps in mitigating such suffering? In my previous research work, I met with several young girls and even men who benefitted from converting religion. It helped them in solving their fainting/possession problems but created other problems like intra-family disputes (children not celebrating dashain while the parents did). I wonder what did you find??

RP: This is a very interesting issue to explore and understand but in our study, this did not come up.

SM: The quantitative results of your study clearly show the need for psychosocial interventions. However, as you mentioned, the participants did not think it to be mental health or psychosocial problems, in such case, what kind of interventions might work??

RP: Yes, you are right that there is a need for psychosocial interventions but as we have mentioned in the paper that biomedical solutions were not helpful, and I believe the same thing about any purely psychological intervention. In addition, I think there is no value in providing education on Western categories of mental disorders (i.e. depression, PTSD, ADHD) when there is no analogical concept of such illness existing in that social and cultural context. This has come up clearly in the paper that people did not accept any biomedical-oriented explanations of this phenomenon. Therefore, we need to provide interventions that are culturally acceptable. However, it is important to note that cultural acceptability does not mean that whether or not the people of different cultural settings receive the medicine or psychotherapy offered to them without resistance. Cultural acceptability, in my understanding, means whether the intervention offered is in-tune with the social and cultural systems of beliefs, knowledge, experiences and worldviews; whether or not the intervention respects the cultural norms and values of people; whether or not the intervention is able support and enhance existing protective factors, traditional understanding and ways of dealing with problems and solve their health problems without harming them.

SM: ‘In the end, the affected women were all treated by performing an extensive village-wide traditional ritual, called ‘‘Khali Khane’’ (Gray 1987). Follow-up with a schoolteacher in April 2012, indicated that, after almost 2 years of continued suffering, the problem in the village had completely stopped, and the villagers had not heard of the fainting episodes in the village, and the shrine is no longer used by anyone.’ This is very interesting end to your story. How did you see this??

RP: Amazing! An example of psychosocial intervention for psychosocial problem.

As we have said in the paper, possession by spirits was not intentional but it served as an idiom of distress and coping strategy for people with psychosocial problems. It is apparent in the paper that existing life situation of these people is not so great. They have various social problems and limited resources available to deal with them. Although, checklist-based assessments of mental health problems had shown higher vulnerability for mental illness for possessed people compared with non-possessed, this does not mean that all the possessed people have mental disorders or going to have one. So, affected people and their family members needed a culturally meaningful explanation for what was going on in the village and kind of assurance that those affected were safe and the existing problem would not have a long term health impact. Khali khane ritual served this purpose.

SM: For your information, I would like to share something about GatheMangalfestival whichNewars celebrate in Kathmandu every year (July – August) to save themselves from the influence of evil spirits. It is believed that at midnight of GatheMangal, witches come for a gathering at the crossroads. http://theweek.myrepublica.com/details.php?news_id=79661.At last, I would like to ask something personal, your belief in evil spirits. Do you think they exist??

RP: Thank you for sharing. See, this is an example of how strongly we believe in spirits and in their ability to influence our lives. I think, it is not a question of whether they exist or not (because no one knows) rather a question of whether you believe that they exist or not. I hope you understand what I mean.

About the Investigator:

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Ram P. Sapkota is a psychologist from Nepal. He is currently enrolled in a PhD program at the Division of Social and Transcultural Psychiatry, McGill University. He is the founding President of Psychosocial Support and Research Centre (PSRC), Nepal – a nongovernmental organization(NGO). He has worked in the field of psychosocial and mental health care for almost a decade in Nepal. His areas of interest include organized violence and its impact on mental health and wellbeing, psychosocial interventions, and global mental health. He is also interested in cultural concepts of distress, traditional healing, and in culture and dissociative phenomena such as trance and possession. Currently, he is involved in a multidisciplinary study on trance and possession phenomena in Nepal. The study aims to produce insights into existing gaps in evidence on the etiology of mass trance and possession by triangulating methods from psychology/psychiatry, neuroscience, and anthropology.

Mental health: Healing the hidden scars


Mental health: Healing the hidden scars

This feature recently published in ICRC website reports about the Mental Health and Psychosocial support programs around the world to recognize the psychological impact of armed conflict and violence, and to help the victims cope and rebuild their lives.

Also includes Nepal program which the ICRC launched the Hateymalo (joining hands together) accompaniment programme in 2010 to help families cope with the uncertainty and to rebuild bonds within communities. The program has already reached out to families of missing in twenty six districts (ten phased out and sixteen ongoing) and still more to reach in seventeen districts this year.