Nepal Earthquakes 2015: Disaster & Mental Health


Nepal faces the risk of different forms of natural disasters like avalanches, floods, earthquakes, landslides, etc. which can potentially create acute short-term impact on the mental health on individual, family, and community levels which can develop into long-term psychosocial and mental health problems if they are not supported and treated on time[1]. The healthcare systems of Nepal government should include mental health and psychosocial support from the primary level in order to facilitate easier access to the services. Some organizations have tried to integrate MHPSS services in primary health care facilities in few districts as a pilot program [2]. The government needs to take interest in such innovative attempts and replicate the program in a larger scale by considering their feasibility and efficacy.

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A damaged house in Dhunchhe, Rasuwa waits for the rebuilding.

Two years after the earthquakes, the adverse impact on physical infrastructure and many aspects of lives is still present in the highly affected districts of Nepal. Majority of the people are still waiting for the government assistance to rebuild their homes. Many people are also in need of mental health and psychosocial services to overcome the adverse effects of the disaster although the level of disorders is low but the distress level among the population is quite high due to different reasons according to the various studies.

Immediately after the earthquakes, there were many national and international organisations providing disaster relief including MHPSS services on the ground which ranged from psychological first aid, community-based psychosocial support programs (psychosocial counseling, support groups, etc), to psychiatric treatment at district headquarter level. The activities covered almost all the levels as illustrated in IASC intervention pyramid [3].

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The Red Cross team interacting with female community health volunteers (FCHVs) in Sindhupalchowk about the impact on mental health and psychosocial wellbeing after earthquakes.

As Red Cross staff, I led the team in Sindhupalchowk few weeks after the earthquakes for providing psychological first aid (PFA) service with team members who had also been trained in physical first aid, it was important to be able to provide support both physically and psychologically. Our work involved providing non-intrusive emotional support, coverage of basic needs through coordination with other units, protection from further harm, reestablishing family links and reinforcing local resilience and social support [4].

Two weeks after the PFA intervention in 5 most affected districts, I visited Gorkha and Dhading, for quick review meeting with field teams and visited some sites to interact locally and observe the impact of the service.  field visit report  [5].

Dr. Dhana Ratna Shakya, Additional Professor, Department of Psychiatry, BPK Institute of Health Sciences (BPKIHS) in Dharan, who conducted a survey among 500 victims of the earthquake in Bhaktapur, reflects, “Through this disaster experience, what I have learned so far is that disasters, as awful as they are, can turn out to be an opportunity for mental health professionals to improve mental health literacy in our communities and sometimes across a whole country.”  Indeed, there has been a lot of investment into reinforcing MHPSS services and increasing mental health literacy and awareness among the people [6].

In addition to providing relief and psychosocial support directly, there were also many attempts on capacity building of stakeholders at local levels who could intervene in absence of trained mental health professionals like psychosocial counselors. For example: Many training programs focused on training health workers to include MHPSS component in their regular services to support people visiting the health posts, teachers’ training to provide emotional and psychosocial support to students at school level, and so on. However, there is a question on the effectiveness of short-term (few days) trainings considering they already have enough workload and there is little incentive and supervision to monitor the changes and how they are making use of the knowledge obtained from the trainings.

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The health worker providing medicine in district health post.

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Trained teacher encouraging students to practice a relaxation exercise at the beginning of his class.

Nevertheless, there have been some reports on the potential misuse of such funding or lack of remarkable results from the MHPSS programs despite heavy expenditure. The critical post by BBC highlighted the immense use of funding for the psychosocial services in the affected districts, mainly Sindhupalchowk and questioned the effectiveness of such programmes which focused on the training of the people [7]. It highlights the need for proper assessment of the psychosocial needs of the people and then after, solid monitoring and evaluation mechanisms in place for the services delivered to show the effectiveness of MHPSS programmes. One of the senior psychiatrists is quoted as saying that after one year of disaster, the psychosocial problems of the people are likely to end which is not realistic given the slow pace and social & political circumstances of the recovery.

We have noticed that disasters tend to aggravate vulnerabilities of rural areas, socially disadvantaged groups, ethnic minorities[8], people living with disabilities, older people, and of women (single women or women who husbands have migrated abroad for work)[9]. In fact, women, constituted a disproportionately high percentage of disaster fatalities. Those who survived, experience risks to personal security, inadequate sanitary/hygiene facilities, exclusion from decision making, and problems in receiving assistance for lack of human resources, information and personal documents [10]. They are also more likely than men to be psychologically affected. Research by Kohrt et al. (2009 &  2012) in rural Nepal has shown gender (female) to be a risk factor for the mental health problems [11a, 11b].

hdr Palsang Lama, Community Psychosocial Worker (ITDS, Nuwakot) is seen here providing home-based counseling session on nutrition to a pregnant woman.

In larger number of cases, persons with disabilities face multiple layers of exclusion and discrimination, such as ethnic woman with disability (visually impaired) who is overwhelmed by hierarchies of gender, caste, and disability, severely limiting her educational, economic, and social opportunities who thus becomes more vulnerable to psychological distress. The woman below from one of the IDP camps is visually impaired who lacked citizenship and disability card, thanks to the psychosocial workers from LACCOS who accompanied her to get them. Now, despite having them, she still lacks opportunities for education and employment.

hdrThe visually impaired woman sharing her difficulties of living as a person with disability in IDP camp.

The study on disaster and disability by Lord et al. (2016) has confirmed prior findings that intellectually disabled persons and people with mental health problems are perhaps the most marginalized and vulnerable group in Nepal [12]. The report consists of three thematic sections which consider the mental health and intellectual disability issues. It discusses about intellectual disabilities & caregivers, underreporting of mental disabilities and the post-earthquake mental health gap. There is clearly a lack of disable-friendly MHPSS programs.

The study done by Tewa and Nagarik Awaz (2016) tried to explore the impacts on the lives of women and men of Bhaktapur [13]. The disaster has forced them to break many cultural norms and experience cultural festivals as moments of sadness, and annoyance instead of the reason for joy, and social cohesiveness. On the positive side, the post-disaster conditions allowed for an increase in social harmony, and solidarity as everybody was suffering from the similar consequences. Females worried about forced separation from a joint family into nuclear families, changes in their roles and life patterns in terms of their daily activities, deprivation of cultural activities such as celebrations of festivals and social gatherings with relatives, psychological distress and need to compromise for a lower standard of life. The males worried that their daily routine has changed as they were compelled to work in the kitchen and care for the babies because women had to spend more time fetching drinking water from distant sources. The gender roles were clearly challenged and men also had to participate in the tasks from which they would otherwise refrain from in normal times.  Males also admitted the increased intake of alcohol with the misconception that it might help them reduce their levels of stress.

The study done by TPO and IMC in three most affected districts: Gorkha, Sindhupalchowk and Kathmandu showed depression among 34.2%, anxiety among 33.8%, PTSD among 5.2%, alcohol use problems among 20.4% and prevalence of suicidal ideation of 11%. It reveals there were high levels of distress but low levels of disorders and functional impairment after four months of the disaster. It also showed that support for mental health problems was provided mainly by traditional healers, religious leaders and staffs mobilized by national and international organizations [14]. The alcohol use problem was prevalent as a negative coping as mentioned in the study above conducted in Bhaktapur. It would be interesting to revisit them and see how they are faring after twenty-four months of the earthquakes.

One of the major learnings of this disaster for Nepal have been to include MHPSS aspect into disaster preparedness in the future.  The agencies coordinating disaster relief need to integrate MHPSS services while providing support for the basic needs as psychosocial support needs are equally important as food, drinking water, shelter, and emergency medical aid. Like Dr. Dhana said above, disaster has also brought some opportunities in MHPSS field, awareness has increased among people regarding mental health issues and resources have also been developed in context of disaster and other situations. The mobile app with helpful information has been developed by TPO Nepal [15].

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Mobile App Screenshot. Also available in web version: manosamajik.com.np

Post Disaster Recovery Framework 2016-2020 of Government of Nepal published by National Reconstruction Authority has envisioned the provision of psychosocial services in education and health sectors under Strategic Recovery objective three: Restore and improve access to services, and improve environmental resilience (p. 8) [16]. Ministry of Health has recently endorsed the revised National Mental Health Policy of 1997, it will go into implementation once it is approved by the cabinet of Nepal government [17].  With that in effect, Nepali people will have improved access to MHPSS services from formal sector in normal times as well as disaster.

References:

  1. Government of Nepal, Ministry of Home Affairs. Nepal Disaster Report 2015

http://www.drrportal.gov.np/uploads/document/329.pdf

  1. Integrating MHPSS services in primary health care facilities in post-earthquake Nepal. Accessed on 24.04.2017, http://www.mhinnovation.net/innovations/integrating-mhpss-services-primary-health-care-facilities-post-earthquake-nepal
  2. Sherchan S, Samuel R, Marahatta K, Anwar N, Van Ommeren MH, Ofrin R. Post-disaster mental health and psychosocial support: experience from the 2015 Nepal earthquake. WHO South-East Asia J Public Health. 2017; 6(1):22–29. http://www.searo.who.int/publications/journals/seajph/issues/seajphv6n1p22.pdf

4. ICRC (2015). Nepal earthquake: Helping communities face their fears https://www.icrc.org/en/document/nepal-earthquake-communities-face-fears

5. Maharjan, S. M. (2015). Field Mission Report: Psychological first Aid Response for earthquake-affected communities.

  1. Shakya, D. R. (2016). The Nepal earthquake: use of a disaster to improve mental health literacy. BJPsych International, 3 (1), 8-9.

7. BBC Nepali Service (2017). ‘एकै जिल्लामा मनोपरामर्शका नाममा डेढ अर्ब’

http://www.bbc.com/nepali/news-38610412

  1. Nepalitimes (2015). Tamang Epiccentre. 10-16 July 2015#766, http://nepalitimes.com/article/nation/April-25-earthquake-Tamang-epicentre,2407
  2. Neumayer, E., & Plumper, T. (2007). The Gendered Nature of Natural Disasters: The Impact of Catastrophic Events on the Gender Gap in Life Expectancy, 1981–2002. Annals of the Association of American Geographers , 551-566.
  3. Halvorson, J. P. (2007). The 2005 Kashmir Earthquake: A Perspective on Women’s Experiences. Mountain Research and Development, 296-301.

11a. Kohrt, B. A., & Worthman, C. M. (2009). Gender and anxiety in Nepal: the role of social support, stressful life events, and structural violence. CNS neuroscience & therapeutics15(3), 237-248. http://onlinelibrary.wiley.com/doi/10.1111/j.1755-5949.2009.00096.x/pdf

11b. Kohrt, B. A., Hruschka, D. J., Worthman, C. M., Kunz, R. D., Baldwin, J. L., Upadhaya, N., … & Jordans, M. J. (2012). Political violence and mental health in Nepal: prospective study. The British Journal of Psychiatry201(4), 268-275. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3461445/

  1. Lord, A., Sijapati, B., Baniya, J., Chand, O., & Ghale, T. (2016). Disaster, Disability, & Difference: A Study of the Challenges Faced by Persons with Disabilities in Post-Earthquake Nepal. Published by Social Science Baha and the United Nations DevelopmentProgramme in Nepal: Kathmandu.
  2. Tewa & Nagarik Aawaz. (2016). A Gendered Look into Bhaktapur’s Recovery and Rebuilding: An Applied Research. Kathmandu, Nepal.
  3. Kane, J. C., Luitel, N. P., Jordans, M. J. D., Kohrt, B. A., Weissbecker, I., & Tol, W. A. (2017). Mental health and psychosocial problems in the aftermath of the Nepal earthquakes: findings from a representative cluster sample survey.Epidemiology and Psychiatric Sciences, 1-10.
  4. TPO Nepal (2016). Andriod App, Manosamajik. https://play.google.com/store/apps/details?id=com.suswasthya.manosamajik.manosamajiksuswastha

16. Nepal Earthquake 2015: Post Disaster Recovery Framework – 2016-2020 http://reliefweb.int/report/nepal/nepal-earthquake-2015-post-disaster-recovery-framework-2016-2020

17. Himalyan Times (2017). Mental health policy coming to effect soon. https://thehimalayantimes.com/nepal/mental-health-policy-coming-effect-soon/

Note: This is a follow up post for the ones I have published earlier, first one three months later and the other one on the occasion of first anniversary. I look forward to receiving your comments and feedback.

And some music from Rohit Shakya with beautiful backdrop of Boudhanath:

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31st International Congress of Psychology (ICP) 2016


The 31st International Congress of Psychology (ICP) 2016 was held in Yokohama, Japan from July 24-29 2016.  This year it was organized around the theme “Diversity in Harmony: Insights from Psychology.”  The ICP is organized by a national host committee under the auspices of the International Union of Psychological Science every four years. The 32nd Congress has been confirmed to be hosted in Prague, Czech Republic in 2020, the dates will be announced soon.

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Princess Akishino Kiko giving a welcome speech during the opening ceremony of ICP.     Photo by: Shirong Zhang (Sharon), Renmin University of China.

The congress was very well-organized and it was a great opportunity to learn about the research and works being done all around the world.

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Professor Kazuo Shigemasu, Chair of Organizing Committee of ICP2016 showing the regional distribution of over 8000 presentations

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Coincidentally, there were just three papers related to Nepal and also three participants from Nepal.

The papers were as follows:

  1. Psychosocial care for cancer patient by Subba, Usha Kiran

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2. Psychosocial Services in Post-Earthquake Nepal by Maharjan, Sujen M

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3.Empirical study of psychological factors and intervention to increase psychological harmony after the earthquake in Nepal by Stueck, Marcus (Germany); Utami, Dian S (Germany); Boehm, Maya (Nepal); Balzer, Hans-ullrich (Germany)

And three Nepali Participants:

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Myself, Usha Subba and Bijay Gyawali (from left).

Some Files: ICP2016_Program_Final & abstractforICP2016_sujenman_nepal

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Fathali on Psychology of Dictatorship & Democracy


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Since 1950s, Nepal have gone through various revolutions and political changes at different points of time that had looked very promising, people hoped for positive changes in everyday lives of Nepali and betterment at all levels. Most recently, Nepal promulgated the new constitution after abolishing the monarchy over 8 years ago. It was welcomed as a historical milestone, the country moved from the political deadlock among monarchy, political parties and Maoists but wait, after all these years, what has happened to the lives of general Nepali who belong to middle-class and lower middle-class so far, the situation is getting tougher. The youth of Nepal is forced to migrate to gulf and other risk-prone countries for survival and to take care of their families. According to ILO, in fiscal year 2014, over  520,000 labour permits were issued to Nepalis for work abroad. High class people continue to hold back the power and dominate the politics. The country suffered devastating earthquakes last year, much of the rebuilding is yet to be started. There is a dissatisfaction among people over new constitution and the lack of right of women to pass on the citizenship to their children among many other issues. On June 14, the government issued online media directives which gives the power to government to crack down over dissenting voices. In democracy, voice is the most crucial aspect of political practice and public lives. Do we feel safe enough to go out and express ourselves at Basantapur Square without fear of police nearby located at Hanumandhoka? What if it reinforces fear to speak up? So, this brings up an important question: have we regressed back and moved even backwards than before? Are we once again heading back to times of dictatorship that our forefathers lived under??

I have found Iranian psychologist Fathali Moghaddam‘s theoretical concepts  useful to understand our political situation from psychological perspective. He has tried to explain the rise and fall of dictatorships through his springboard model in which he says that the context that lead to the rise of the dictator is more important the personality of the leader. In traditional psychology, the personality of the dictating leader is studied to understand the dictatorship but he prioritizes context and collective over individual processes to understand dictatorship and democracy.

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Where does Nepal like on the continuum between dictatorship and democracy???

Fathali also writes about the development of psychology in third-world countries like Nepal. His publications can be read here: http://fathalimoghaddam.com/?page_id=18

From Public Lecture about the book: http://www.iop.or.jp/Documents/1626/%5B125-138%5DJournal26_Moghaddam.pdf [125-138]Journal26_Moghaddam

Seminar on Contemporary Research in Psychology in Nepal


Last week, a seminar on ‘Contemporary Research in Psychology in Nepal’ was organised by Nepalese Psychological Association (NPA) and Central Department of Psychology (TU) on 28 May 2016  (15 Jestha 2073, Saturday) at Padma Kanya Campus, Kathmandu.

The program started with formalities and speeches as usual. It was followed by paper presentations by 8 professionals and students who are engaged in research work. I was invited to present my paper on ‘Bibliography of Psychological Research in Nepal.’ See full schedule here: seminarNPA2016schedule

The first session was chaired by Prof. Dr. Santa Niraula, Head of Psychology Department, TU in which 4 papers were presented:

1) ‘Feasibility Study on Development of Children’s Emotional and behavioral problem checklist’ . By Suraj Shakya & Sunita Shrestha
2) ‘Ethnic Self-Labeling Among Nepalese Adolescents’ by Sandesh Dhakal
3) ‘Bibliography of Psychological Research in Nepal’ by Sujen Man Maharjan
4) ‘Survey on Psychological Well-being and perceived organizational support in the aftermath of Nepal Earthquake’ by Yubaraj Adhikari.

The session ended after the brief discussion on the papers and closing remarks by Dr. Niraula.

The second session was chaired by Prof Dr. Mita Rana, MPhil Clinical Psychology Department Head of TUTH in which 4 papers were presented:

1) ‘Prevalence of PTSD and its Influencing Factors Among the Government School Teachers After Nepal Earthquake 2015’ by Ganesh Amgain
2) ‘Possibility of Mental Illness in Adults Affected by Gorkha Earthquake in Tudikhel Camp- A Survey’ by Sujan Shrestha and Kripa Sigdel
3) ‘Home and Health Adjustment Among College Students with Their Locale of Five Development Region’ by Padam Raj Joshi
4) ‘Adolescents’ Concern non Problems with their Parents’ by Khem Raj Bhatta

The session ended after the brief discussion on the papers and closing remarks by Dr. Rana.

The program concluded with the closing speech by Dr. Nandita Sharma, Vice President of NPA.

The participation of the students was very enthusiastic. There were over 250 participants from different public and private colleges in Kathmandu, mostly students who are studying Psychology in Bachelor and Master levels. I remember this event had been organised after a long time, I wrote about similar event that took place five years back when I had presented my poster based on my MA thesis.

This program could have been better organized if the time had been properly set and logistics were in place properly. There were few shortcomings in the management but the program being organized deserves appreciation and I hope such events will be regularly organized, not after many years.

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Participants coming for the program in the PK premises.

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Distinguished guests of the program.

 

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Over 250 Participants were present in the seminar.

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The group picture of the paper presenters on bottom and professors & psychologists on the upper row.

 

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The group picture of participants, presenters and organizers.  WE ROCK!!

Thanks to the organizers for the opportunity to present the paper and the participants for showing so much interest in my paper. For those of you who did not receive the tiny handout of my presentation, here is the information to access the file:

Maharjan, S. M. (2012). Bibliography of Psychological Research in Nepal. [PDF file]  Retrieved from http://www.martinchautari.org.np/2012-08-27-08-45-41/bibilographies.html http://bit.ly/1TMOftz

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:

rp

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.