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Service Delivery Innovation Profile

Refugee Trauma Program Uses Novel Approach to Promote Recovery for Victims of Violence, Other Trauma


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Snapshot

Summary

The Harvard Program in Refugee Trauma developed and now promotes a novel approach to identifying and treating refugees who are victims of trauma. The Harvard Program in Refugee Trauma helps these individuals face their fears and play an active role in their own self-healing process and provides culturally competent counseling that encourages victims to share their stories as part of the therapeutic process. Unpublished results from Harvard Program in Refugee Trauma's activities in the Boston area, along with several published studies, have shown that this type of approach can be effective in improving outcomes; other studies have validated the effectiveness of Harvard Program in Refugee Trauma screening tools and training programs.

Evidence Rating (What is this?)

Suggestive: The evidence consists of post-implementation data on the Harvard Program in Refugee Trauma's success in achieving remission among patients in the Boston area, along with several studies from other settings that track outcomes of patients treated with elements of the Harvard Program in Refugee Trauma approach.
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Developing Organizations

Harvard Program in Refugee Trauma
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Use By Other Organizations

Although the Harvard Program in Refugee Trauma approach is unique, it has much in common with scores of other community and academic initiatives that have emerged worldwide over the past 30 years, including the New South Wales Torture and Trauma Service in Sydney, Australia; the Transcultural Psychology and Psychiatry Program at the Karolinska Institute's Program on Migration and Health in Sweden; the International Rehabilitation Council for Torture Victims in Denmark; the Medical Foundation in London, England; and the Association pour les Victims de la Repression en Exil in Paris, France. In addition, a number of countries in Africa, Asia, Central America, and South America are developing centers of excellence to respond to the physical and mental health needs of their populations, including new arrivals who are fleeing war and violence.

Date First Implemented

1981
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Patient Population

Race and Ethnicity > Asian; Vulnerable Populations > Immigrantsend pp

Problem Addressed

Refugees who are victims of trauma, including both natural disasters and human-inflicted violence, suffer devastating physical, emotional, and social health consequences but often have little or no access to mental health services that can help them deal with and recover from their tragedy. When such services are available, they are often based on faulty assumptions, biases, and opinions.
  • Devastating, lasting consequences: Several studies have documented the long-lasting negative physical, emotional, and social health consequences of trauma experienced by refugees. For example, a 1990 study of a Thai-Cambodian refugee camp found that the average refugee had experienced 16 major trauma events, such as torture or rape, and as a result, experienced high levels of emotional distress. A 1996 longitudinal study of Bosnian refugees found a high prevalence of mental health problems that were unremitting, disabling, and associated with premature death.1
  • Lack of access to services: Many newly arriving refugees are extremely poor and generally excluded from existing public and private health systems.2
  • Care based on faulty assumptions when provided: Those refugees who can access the health system often receive care that is based on faulty assumptions, including that the patient does not have mental health problems; that the patient is incapable of providing insights into these problems (if they do exist); and that rehabilitation/recovery from traumatic experiences is generally not possible.2
  • Little or no counseling from trained, culturally aware clinicians: Refugee patients rarely receive psychotherapy and/or other mental health services; most providers merely offer prescription drugs. When such services are offered, they are typically provided by mental health workers with limited understanding of the culture of the patients being served.2

What They Did

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Description of the Innovative Activity

The Harvard Program in Refugee Trauma has developed and promotes use of a novel approach to identifying and treating refugees who are victims of trauma, including natural disasters and violence—such as rape, torture, and genocide. The Harvard Program in Refugee Trauma approach relies on culturally competent clinicians who work closely with victims over time to come to terms with the horrors they have faced and to reclaim meaning and purpose in their lives. Key elements of this approach are highlighted below:
  • Cultural competence and acceptance: The Harvard Program in Refugee Trauma approach advocates employment of trained, bicultural workers who are of the same ethnic background as the target population. These individuals work closely with the psychiatrist or other mental health professional to contextualize the history of patients and provide insights into the cultural manifestations among different societies.2
  • Abandonment of all preconceived notions: Under the Harvard Program in Refugee Trauma approach, providers abandon currently held theories, opinions, and biases, including the idea that torture survivors are not ready to talk about their life experiences and that they express their depressed feelings through physical complaints.2
  • Initial, semistructured interviews to identify and diagnose victims: Using any of a variety of validated screening instruments, providers engage refugees in a guided but open-ended interview. These tools are also used on a periodic basis to monitor each patient's progress.
  • Explicit commitment to long-term treatment focused on recovery and rehabilitation: The Harvard Program in Refugee Trauma approach emphasizes a long-term commitment to working with the trauma victim. Sessions (usually weekly) focus on slowly reducing symptoms and developing a more hopeful attitude. Periodic reminder phone calls may be useful to help establish trust and confidence among patients. Key elements of the treatment process include the following:
    • Eliciting the "trauma story": The therapist attempts to draw the story out of the refugee over time, a process that can prove therapeutic to the patient and also helps the therapist to understand and acknowledge the experience.
    • Dealing with psychological states of mind: The therapist helps the patient to recognize and deal with four trauma-induced psychological states of mind, including humiliation, anger, revenge/hatred, and hopelessness/despair.
    • Dealing with emotional states: Therapists strive to help the patient achieve insight into the causes and consequences of their problems and to reduce their negative emotional impact.
    • Dealing with physical and mental health problems: Torture and other forms of mass violence can result in major medical problems (head injury, pain, and disability due to land mines and shrapnel, and the medical consequences of sexual abuse) and mental health problems such as chronic depression.
    • Providing and/or arranging for social services: Therapists arrange for social services that help the survivor repair his or her physical and social world, including assistance with housing, employment, and material possessions. Patients may also need legal assistance and language training.
  • Ongoing monitoring: In recent years, the Harvard Program in Refugee Trauma has begun to monitor a patient's health status constantly and to reevaluate the progress of each refugee patient every 6 months. This "push-to-cure" approach leads to changes in the therapy if positive results have not been achieved during the previous 6-month period. Typically, success is defined by getting the patient to the point that they are not having any major ongoing symptoms from their trauma.

Context of the Innovation

The Harvard Program in Refugee Trauma, originally founded at the Harvard School of Public Health, developed the first curriculum for training primary care practitioners in settings of human conflict, postconflict, and natural disasters. The program was founded in the early 1980s by Richard F. Mollica, MD, who realized that the growing population of refugees from Southeast Asia were not well served by existing public, private, and academic medical systems. Working with James Lavelle, a social worker already active in the refugee community, Dr. Mollica set up a small free clinic for these refugees in the Brighton section of Boston. Initially known as the Indochinese Psychiatry Clinic, this initiative later expanded and transitioned into the Harvard Program in Refugee Trauma, which focuses on training providers to offer this kind of care to trauma refugees throughout the world.

Did It Work?

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Results

Unpublished post-implementation results from the Harvard Program in Refugee Trauma's activities in the Boston area, along with several small time-series studies on programs that include elements of the Harvard Program in Refugee Trauma, have documented the effectiveness of the approach in improving outcomes for refugee trauma victims over a period of time. In addition, the screening tools and training programs used by the Harvard Program in Refugee Trauma have been validated as being effective.
  • Many patients achieving remission in Boston area: Anecdotal, unpublished data suggest that the Harvard Program in Refugee Trauma's work in the Boston area is currently achieving roughly 80-percent rates of cessation of symptoms, and the return to relatively normal physical and mental functioning. The percentage of patients achieving remission increased substantially over the last few years after the Harvard Program in Refugee Trauma initiated its "push-to-cure" approach that emphasizes ongoing monitoring of health status and twice-a-year reevaluations.
  • Modest improvements in outcomes in several small published studies: An evaluation of symptoms and levels of perceived distress among 52 highly traumatized patients (21 Cambodian, 13 Hmong/Laotian, and 18 Vietnamese) before and after a 6-month treatment period found that most patients improved significantly.3 A second study of 23 severely traumatized Cambodian refugees with posttraumatic stress disorder over 10 years found that 60 percent of patients greatly improved.4
  • Validation of screening tools and training programs: A validation study found that the Hopkins Symptom Checklist-25 (HSCL-25) screening tool has been well received by refugee patients, that it offers an effective screening method for the psychiatric symptoms of anxiety and depression, and that it is especially helpful for evaluating trauma victims.5 An evaluation of a 2-year Harvard Program in Refugee Trauma training program used for providers in primary care settings in Cambodia found that the program resulted in a significant improvement in primary care physicians' confidence in all clusters of medical and psychiatric procedures.6

Evidence Rating (What is this?)

Suggestive: The evidence consists of post-implementation data on the Harvard Program in Refugee Trauma's success in achieving remission among patients in the Boston area, along with several studies from other settings that track outcomes of patients treated with elements of the Harvard Program in Refugee Trauma approach.

How They Did It

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Planning and Development Process

Key steps in implementing the Harvard Program in Refugee Trauma approach include the following:
  • Training: Over the past 22 years, the Harvard Program in Refugee Trauma has trained thousands in the United States and abroad—including providers in medicine, psychiatry, and traditional healing; social service agencies; and United Nations–affiliated and nongovernmental organizations. The Harvard Program in Refugee Trauma provides several different types of training, including local training to providers in Massachusetts; a 1-week "master" class that brings together clinicians from societies where conflicts and violence are common; country-specific provider training that generally lasts 1 to 2 years (sessions have been held in Cambodia, Bosnia, and Peru); and a Global Mental Health Recovery Program.
  • Adapting structured questionnaires to local settings: The structured instruments, including the Hopkins Symptom Checklist-25 and Harvard Trauma Questionnaire, were developed so they can be adapted to local settings internationally. More details can be found at http://hprt-cambridge.org/?page_id=42.

Resources Used and Skills Needed

  • Staffing: The Harvard Program in Refugee Trauma approach can be adopted by any primary care practice, community clinic, or mental health center. Providers must speak the language of the population being served or have access to interpreters who also understand the patient's cultural background.
  • Costs: The expenses associated with implementing this approach consist primarily of training and securing access to appropriate interpreter services. Clinical services provided to patients are generally reimbursable through the patient's public or private insurance coverage.
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Funding Sources

Office of Refugee Resettlement; World Bank
The Harvard Program in Refugee Trauma is currently in the third year of a 4-year grant from the Office of Refugee Resettlement to provide community-based clinical care for torture survivors residing in Massachusetts. Many other organizations, including the World Bank, the Substance Abuse and Mental Health Services Administration, the US Office of Refugee Settlement, the U.S. Fulbright Commission, The Peter C. Alderman Foundation, the Open Society Fund for Bosnia-Herzegovina/Soros Foundation, and the National Institute of Mental Health, are currently supporting various Harvard Program in Refugee Trauma activities. A partial list of past sponsors includes Amnesty International, Bank of Boston, Fidelity Trust, Ford Foundation, Japan Foundation Center for Global Partnership, the Massachusetts Department of Health, Pew Charitable Trusts, and the U.S. Agency for International Development.end fs

Tools and Other Resources

The Harvard Program in Refugee Trauma and other collaborating organizations offer a variety of materials to assist would-be adopters, including the following:
  • Toolkit: A toolkit, available through the Harvard Program in Refugee Trauma office, provides detailed guidance on the 11 components that make up a holistic approach to providing effective care to refugee trauma victims. For each component, the kit includes a small manual, textbook, and CD-ROM. The Harvard Program in Refugee Trauma also offers a mini-toolkit on use of antidepressants in culturally diverse populations.
  • Certificate program: The Harvard Program in Refugee Trauma's Global Mental Health: Trauma and Recovery Certificate Program is disseminating the treatment philosophy of the original Indochinese Psychiatry Clinic and Harvard Program in Refugee Trauma.
  • Action plan and best-practice publication: As part of Project One Billion, the Harvard Program in Refugee Trauma and other partners have developed a Mental Health Action Plan and a soon-to-be-released book of best practices.
  • Torture treatment centers: Would-be adopters can also receive assistance from any of 25 to 30 torture treatment centers that operate in the United States; a list of these centers is available from The Substance Abuse and Mental Health Services Administration Office of Refugee Mental Health.

Adoption Considerations

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Getting Started with This Innovation

  • Position the program as a logical extension of larger movements: The need to provide culturally competent care to refugee trauma victims is part of larger movements in the field, including efforts to encourage primary care physicians to identify and treat domestic violence and depression, and to provide culturally competent care to diverse populations of patients.
  • "Sell" providers by emphasizing that this approach need not consume too much time: Many providers feel that they do not have the time to engage refugee patients in this kind of approach during a short office visit. Because dealing with past trauma is generally not an "emergency" situation, the victim's story can safely be drawn out in bits and pieces during a series of sessions, using as little as 5 minutes at a time.

Sustaining This Innovation

Do not reinvent the wheel: The Harvard Program in Refugee Trauma's clinical, educational, research, and policy initiatives have been well established over the last 3 decades. Would-be adopters should take advantage of the many available resources (e.g., training programs, toolkits).

Spreading This Innovation

The Harvard Program in Refugee Trauma approach has been used by public and private organizations in many developed and developing nations, including Bosnia-Herzegovina, Cambodia, Croatia, Japan, Iraq, Afghanistan, Peru, Rwanda, and Uganda.

Use By Other Organizations

Although the Harvard Program in Refugee Trauma approach is unique, it has much in common with scores of other community and academic initiatives that have emerged worldwide over the past 30 years, including the New South Wales Torture and Trauma Service in Sydney, Australia; the Transcultural Psychology and Psychiatry Program at the Karolinska Institute's Program on Migration and Health in Sweden; the International Rehabilitation Council for Torture Victims in Denmark; the Medical Foundation in London, England; and the Association pour les Victims de la Repression en Exil in Paris, France. In addition, a number of countries in Africa, Asia, Central America, and South America are developing centers of excellence to respond to the physical and mental health needs of their populations, including new arrivals who are fleeing war and violence.

Additional Considerations

  • Use screening instruments (not informal interviews) to engage patients: Use of validated screening instruments has proven to be an effective way to engage patients, who report that they appreciate having the opportunity to discuss and come to grips with their past.
  • Develop an understanding of pharmacology as it relates to ethnic groups: Different ethnic groups react in different ways to various medications, including antidepressants. For example, Asians, Hispanics, and African Americans tend to need lower doses of antidepressants than do Whites.
  • Focus on specific symptoms, not conditions or diseases: For example, rather than focusing on treating posttraumatic stress disorder as a whole, providers should take concrete actions designed to deal with the specific problems facing the traumatized patient, such as pain, insomnia, and stress.
  • Monitor progress over time and make adjustments as needed: The validated tools can be used to periodically monitor a patient's progress. Adjustments can be made every 6 months if a patient is not progressing toward remission.

More Information

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Contact the Innovator

Richard F. Mollica, MD
Director
Harvard Program in Refugee Trauma
Department of Psychiatry
Massachusetts General Hospital
22 Putnam Avenue
Cambridge, MA 02139 USA
Phone: (617) 876-7879
Fax: (617) 876-2360
E-mail: rmollica@partners.org

Innovator Disclosures

Dr. Mollica has not indicated whether he has financial interests or business/professional affiliations relevant to the work described in this profile; however, information on funders is available in the Funding Sources section.

References/Related Articles

Mollica RF. Healing Invisible Wounds: Paths to Hope and Recovery in a Violent World. Orlando, FL: Harcourt, Inc., 2006.

A complete list of references and related articles is available at http://hprt-cambridge.org/?page_id=82.  

Footnotes

1 For a complete list of Harvard Program in Refugee Trauma studies on the impact of trauma, see http://hprt-cambridge.org/?page_id=80.
2 Mollica RF. Healing Invisible Wounds: Paths to Hope and Recovery in a Violent World. Orlando, FL: Harcourt, Inc., 2006.
3 Mollica RF, Wyshak G, Lavelle J, et al. Assessing symptom change in Southeast Asian refugee survivors of mass violence and torture. Am J Psychiatry. 1990;147(1):83-8. [PubMed]
4 Boehnlein JK, Kinzie JD, Sekiya U, et al. A ten-year treatment outcomes study of traumatized Cambodian refugees. J Nerv Ment Dis. 2004;192(10):658-63. [PubMed]
5 Mollica RF, Wyshak G, de Marneffe D, et al. Indochinese versions of the Hopkins Symptom Checklist-25: a screening instrument for the psychiatric care of refugees. Am J Psychiatry. 1987;144(4):497-500. [PubMed]
6 Henderson DC, Mollica RF, Tor S, et al. Building primary care practitioners' attitudes and confidence in mental health skills in a post-conflict society: a Cambodian example. J Nerv Ment Dis. 2005;193(8):551-9. [PubMed]
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Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read more.

Original publication: February 02, 2009.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: February 12, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: April 30, 2010.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.