Capacity Building Methods for
Providers of Mental Health
Interventions
with Trauma Survivors
in Low Resource Countries
Center for Victims of
Torture
(CVT)
Minneapolis, Minnesota
David R. Johnson, MD, MPH
Linda Nielsen, MSW, LICSW
Pamela Santoso, MPH (cand.)
Carol White, MS, MPH (cand.)
Neal Porter, MA, MPPM
“To heal the wounds on
individuals, their
families, and their
communities and to stop
torture worldwide.”
 Center for Victims of Torture, 2003
CVT is a hybrid health care &
human rights organization
• I. Target population:
– Survivors of government-sanctioned torture or politicallymotivated violence
• II. Human Rights / Advocacy work:
–
–
–
–
New Tactics for Human Rights ( www.newtactics.org )
Public policy work on Torture Victims Relief Act
Public policy work on US use of torture
Participate in national consortium of torture treatment centers
• III. Local health care and capacity building
– Two treatment centers in Minnesota using a multidisciplinary
approach to treating torture survivors from over 60 countries
– Ongoing trainings of local health professionals
– New Neighbors Hidden Scars networking and capacity building
project for community organizations working with survivors.
• IV. National Capacity Building
– Lead capacity building project with local torture treatment centers
to develop organizational, clinical, advocacy and research
capacity.
CVT International Projects
International
Services
International
Capacity
Building
Project
Trauma Healing
Initiative Cambodia
Provides direct
services, training /
capacity building, &
community
sensitization.
Builds clinical,
organizational, &
advocacy capacity of
foreign torture
treatment centers.
Develops capacity of
government & nongovernmental service
providers, & expands
resource network
-Sierra Leone
-Liberia
-Democratic
Republic of Congo
-Sudan, Ethiopia,
Rwanda, Uganda,
Kenya, Cameroon,
Namibia, S. Africa.
-Bangladesh, India,
Cambodia, Pakistan
-Palestine, others.
-Cambodia
-Works with multiple
in country
organizations
Guidelines for International Training in MH & Psychosocial
Interventions
For Trauma Exposed Populations in Clinical and Community
Settings
Weine, S., Danieli, Y., Silove, D., van Ommeren, M., Fairbank, J., & Saul, J.
Values
-Respectful
-Scientific
-Legitimacy of
multiple
perspectives
-Open dialog
-Integrating
differing
perspectives
Contextual
Challenges
-Culturally sensitive
-Entering insecure
environments
-Needs of all
subgroups considered
-Integrated with
development efforts
-Address short & long
term challenges
-Transparent
-Uses public health
principles
Core Curricular
Training Elements
Monitoring &
Evaluation
-Listening & communication
skills
-Assessment
-Interventions to diminish
distress
-Understand local context
-Problem solving strategies
-Treat unexplained somatic
pain
-Ongoing supervision
structure
-Covers self care
-Training include
monitoring / eval.
-Identify objective
w/ needs assess.
-Identify process
indicators
-Indicators to
evaluate impact on
trainees skills, on
services, and on
beneficiaries.
-Use appropriate
approaches
-Report / dissem.
Contrast Three Diverse Models of
International Capacity Building
• Project description & • Strengths &
challenges of model:
Target population
• Model selection
process
• Lessons learned
from project
implementation
– Control
– Scope / beneficiaries
– Sustainability
– Effectiveness
• Evaluation strategies
• Ethics
Center for Victims of Torture
International Services Program
CVT International Services Program
Description
• Countries with large population of highly
traumatized refugees/returnees Liberia, Sierra
Leone, Dem. Rep. Congo
• Qualified expatriate Clinicians provide
intensive hands on training to national
staff - Psychosocial Counselors (PSCs)
Current CVT International Services
Programs (ISP)
Sierra Leone
Kono district communities
Liberia
• Monrovia
• Lofa County
• Bong County
Dem. Republic of Congo
• Communities in Katanga
district (Pweto and Lubumbashi)
CVT ISP Key Activities
I. PSC Training
2. Client Care
3. Community Outreach
Key Activity 1 – Training the PSCs
CVT Clinicians recruit and train Psychosocial Counselors
(PSCs) from the refugee community.
The PSCs start an intensive training program that continues
throughout their career with CVT.
Key Activity 1 – Training the PSCs
PSCs serve as interpreters and cultural brokers
and help to adapt counseling models to local
settings
• Initial two-week training
• Pre- and post-testing
• First, PSC observes Clinician lead
session
• PSC co-leads, then leads
• Clinician observes and provides
feedback to PSC
• Ongoing monthly focused 1-3
day workshops
Key Activity 2 –Client Care
Elements of direct mental health services
• Client identification
• Intake assessment
• Group or individual treatment planning
• Counseling sessions
• Follow-up client assessments
• Home and family visits
• Referrals to other agencies
Key Activity 2 – Client Care
Small Group Counseling
– Sessions provide psychoeducation and opportunity for trauma
processing
– Sessions average 8-10 weeks, 1.5 hours per week
– Groups average 6-12 members
– PSCs participate initially as interpreters, then learn how to facilitate
groups on their own
Individual Counseling
– For clients unable to attend group sessions due to extremity of
symptoms or with a great need to address problems 1:1
– Carried out by expatriate Clinicians until PSCs ready to counsel on
their own
Counseling hut and PSCs
Key Activity 3 - Community
Sensitizations
• Raise awareness of
the prevalence and
effects of torture
• Help community
members know what
CVT does to help
survivors
• Help identify potential
clients.
Key Activity 3 – Community
Psychosocial Activities
• Provide activities such as
games, drama, arts and crafts,
and sports activities provided
regularly
• Engage the community in the
healing process, promoting
positive extra-curricular activities
for clients.
• Help identify new clients.
Target PopulationsBeneficiaries
• Survivors of torture and their families in
refugee settings or communities of return
• National Staff trained to serve as PSCs
• Staff at other agencies and community
leaders
Model Selection/Context
Indigenous capacity in mental health service provision
is non-existent or destroyed
Torture extremely prevalent among target populationmore than 50%
Availability of partner agencies nearby to provide basic
needs, security
Need to have enough staff to address high risk of
vicarious trauma for both expats and local staff
CVT ISP Strengths/Challenges
Strengths of ISP
Hands-on, immediate, continuous clinical supervision and
training, allows for long-term professional and documentable
skills building
Easier to document improvement in clients
Easier to adapt western therapy models to indigenous culture
Potential to integrate learning back at CVT headquarters
Immediate post-conflict response and treatment but have to
balance with security issues
PSCs heal from their own trauma through their work at CVT Relationships with families and others are improved
Challenges of ISP
Challenge to find qualified expatriate Clinicians and
And its very
integrate respective skills/interests
expensive!
Full program means covering all security, financial
accountability, human resources, personnel
management remotely
Building capacity of national staff to be more independent
providers requires 4-5 years minimum
Consistency required in services and training when much is
uncertain (funding, political conditions, logistics)
Community acceptance of mental health mission difficult
with high material needs of beneficiaries
ISP Scope
Over the 3 programs in Sierra Leone, DRC and Liberia
2,227 clients received direct counseling in 2006
10,714 clients since 1999
1 expatriate clinician required to supervise 12-15 PSCs
88 PSCs and 6 expatriate clinicians currently
Over 250 PSCs trained since 1999
26,671 community members participated in sensitization in
2006
1,951 NGO partners, health care, teachers and community
leaders trained in 2006
ISP Scope
Sierra Leone
Kono district
communities
Admin office in
Freetown
Pweto
Liberia
Lofa
Dem. Republic of
County
Congo
Bong
Katanga district
County
(Pweto and
Monrovia
Lubumbashi)
Four to five communities for each site in each country
Sustainability
• Must build skills of entire staff, not just PSCs, to
ensure long-term sustainability
• Requires a resource rich and/or diversified
donor base to meet the costs
• Requires clear justification to donors of need for
development of national staff as mental heath
paraprofessionals and of time it requires
Effectiveness
• Better ability to document improvement in
clients through long-term follow up
• Widely accepted in communities of
operation after initial skepticism
• Good response to services from
communities and partner agencies
Evaluation
• Clients-- at 3-month intervals,
symptoms; social support;
behavioral functioning
• PSCs--internal trainings and
performance
• External training of partners,
health care, teachers, religious
and community leaders
• Clinicians--performance
PSC Evaluation
Assessed through regular observation, supervision,
written reports
Receive monthly trainings with pre- and post-tests
Semi-annual performance evaluation
•Client care
•Community outreach
•Training skills
•Demonstration of ethical conduct
•Group facilitation skills
•Learning and listening skills
Lessons Learned
•
•
•
•
Need to make sure there are enough resources
Good field management essential
Good financial management essential
Orientation to CVT organizational culture
important
• Not stretch staff too thinly
– Concentrate staff in minimal number of sites
• Communities of return more challenging than
refugee camps Tired clinicians
• Support is crucial
Ethical Considerations
• How to address the issue of ongoing
clinical supervision
• What can we offer our staff in terms of a
“leave behind” piece?
• How to practice as a Human Rights
organization
• Standards of practice (confidentiality, etc)
CVT ISP Staff
From Left to right, back row Neal Porter, Jon Hubbard, Ivan DeKam,
Jean-Baptiste Mikulu, Gwen Vogel, Nelson Kaputo, Cathy Mwaniki, Alieu
Sannoh. Front row from left, Amy Jo Versolato, Yuvenalis Omagwa,
Sharon Gschaider, Linda Nielsen, Edie Lewison, Michael Kamau Kariuki
International Capacity
Building Project
Building capacity of torture treatment
centers
Pamela Kriege Santoso
The Center for Victims of Torture
October 31, 2007
Goal of the ICB Project
• Work with torture treatment centers to
strengthen their capacities:
– Clinical
– Organizational
– Technological
– Advocacy
So better positioned to be sustainable and
provide effective services
Context:
Role of Torture Treatment Centers
• About 200 torture treatment centers
worldwide
• Small, isolated, lacking social support
• Specialized programs can contribute to
building of knowledge of torture treatment
Context:
Role of Torture Treatment Centers
• Unique role as healers for treatment and
advocacy
• Design interventions that are appropriate
for local and regional circumstances
Torture Treatment and Rehabilitation
Partner Centers
Bucharest, Romania
Financial management training leading to update
of internal financial management system
Sofia, Bulgaria
Rehabilitation services to torture survivors from Turkish minority
and establishment of mobile units in Varna and Isperih
Pristine, Kosovo
Rehabilitation services, advocacy, and training of
professionals and students, CBT training for staff
Islamabad, Pakistan
Ramallah, Palestine
Rehabilitation and monitoring of torture cases in local prisons, training workshops
New offices in north and south of West Bank, and
evaluation of internal and external services
Guatemala City, Guatemala
Kono, Sierra Leone
Psychosocial monitoring during mass
grave exhumations, and staff
development in technology use and
mental health methodology
CVT provides direct counseling services
and trains local psychosocial counselors
Khartoum, Sudan
Yaounde, Cameroon
Technology acquisition, public awareness raising efforts, staff
development trainings, legal services to torture survivors
Clinical and technological skills training
and direct services
Dhaka, Bangladesh
Community outreach programs, torture prevention training for
health and law enforcement professionals, and advocacy work
Addis Ababa, Ethiopia
Kampala, Uganda
Lima, Peru
New Delhi, India
Rehabilitation services and training of
health, law, and human rights professionals
Kigali, Rwanda
Rehabilitation services and anti-torture
education training
Nairobi, Kenya
Forensic work and monitoring of prison detainees
Rehabilitation services, torture prevention
efforts, staff development training
Windhoek, Namibia
Rehabilitation services and mobile clinic in
northern regions and staff development training
Cape Town, South Africa
Organizational development, advocacy and
lobbying, program management training
Phnom Penh, Cambodia
Trauma Healing Initiative (THI) – Building clinical and
public education capacity among a network of torture
treatment resources
Key Project Activities
•
•
•
•
•
•
•
•
Organizational assessments
Operational sub-grants
Technology sub-grants
In-country technical assistance from local
or international consultants
Workshops
Staff exchanges
Database and website development
Monitoring and ongoing follow-up
coaching
Centro de Atencion Psicosocial
(CAPS), Peru
“The unique aspect of this project is that it
helps us identify our institutional needs,
while respecting our own goals and
timeframe for the institution.”
Examples of Service Delivery
enhancement
•
•
•
•
•
•
•
•
•
Salaries for clinicians / new staff
Community assessments
New programs (for children, refugees, prisoners)
Mobile clinics
Training of other professionals
Supervision
Training on counseling skills, techniques
Workshops
Exchanges with other centers
Evaluation: Organizational Matrix
Functional Areas:
A. Governance
B. Organizational Operations and Management Systems
C. Human Resources
D. Financial Resources
E. Service Delivery
F. Information Technology
G. External Relations
Ratings:
• Emerging
• Developing
• Consolidating
• Sustaining
E. Service Delivery
• The quality of service delivery is the strongest
indicator of the success and effectiveness of
an organization. A viable organization not
only provides quality services to meet
community needs but also is able to provide
this level of excellence over time. Two
principle activities/outcomes that need to be
considered are: Direct Services to clients
and Public Education.
SECTORAL
EXPERTISE
IMPACT
ASSESSMENT
Emerging
Developing
Consolidating
Sustaining
Organization has
limited track record in
sector and area of
service delivery but
some good ideas
about how to meet
needs of target
community/constituen
cies. It has little
operational
experience however
and no specialization
in the sector.
Improved targeting
and redefined
service/technical
assistance package.
Growing expertise in
technical area and
ability to access
additional expertise in
that area when
required.
Client base well
defined and well
reached. Efficient
delivery of
appropriate services.
Fee for service and
other cost recovery
mechanisms being
built in to service
delivery process.
Organization being
recognized as having
significant expertise
in technical area and
being invited to
contribute to these
areas.
Organization is able
to adapt program and
other service delivery
capacities to
changing needs of
constituency and to
deliver services to
additional
communities/
constituencies. Full
recognition as
experts in technical
area and given
consultative status in
those sectors by
government and
other multi-sectoral
organizations.
Organization does
not systematically
monitor or evaluate
program/project
achievements against
projected or planned
activities. It does not
measure overall
impact and has not
determined impact
indicators or
established baseline
measures of
indicators.
Individual projects
evaluated to
determine if projected
activities took place
as planned and if
specific project
objectives were
achieved. These
objectives may or
may not be
measurable.
The Organization is
aware of the issue of
program sustainability
and is exploring how
to measure impact.
There are no overall
impact indicators
selected and no
baseline data
available or accessed
to provide basis of
comparison.
Measurable
indicators of success
and impact have
been determined.
Studies are
conducted or
accessed which
provide baseline
measures. This
information is
regularly remeasured.
Development of a Clinical Matrix
for Torture Treatment Services
• Clinical Program Management
• Clinical Processes
–
–
–
–
–
–
–
–
Accessibility / physical premises
Client intake
Clinical records
Clinical Training and Experience
Staff Clinical Supervision
Staff Self-Care
Staff performance evaluation
Client Services
• Overall Program Impact / Evaluation
• Developing Healthcare Pathways for Constituents
• Individual Client Outcome Measures
2.2 Client Intake
Emerging
Developing
Consolidating
Sustaining
2a) Target group not
well defined and/or not
clear to others.
2a) Target group clearly
delineated and
specified externally.
2b) Initial client
screening process
conducted by nonclinician or
inexperienced clinician.
2b) Initial client
screening process
conducted by
experienced clinician.
2c) Limited client
education about
principles of information
and treatment
confidentiality.
2c) Extensive client
education about
principles of
information and
treatment
confidentiality.
Strengths of this model
• Centers already exist – no start-up
• Locally run
• Partners actively involved in developing
training and technical assistance plan
• Can learn from other centers in project
• Strengthens worldwide movement
• Holistic approach: not just focused on
Clinical Training
Challenges of this model
• Treatment centers not always where there is need
• Source of funding may limit partners
• Lack of trained mental health professionals in many
developing countries; university and other training
• Takes time and funding to improve clinical skills
• Interest in new techniques while needing basic skills
• Loss of staff to higher paying Intl. NGOs
• Hard for CVT to measure impact on beneficiaries
• Partners ultimately in control of decisions
• Risk of dependency on CVT funds
Lessons Learned
• Strong personal relationships are key
• Basic counseling skills still needed
• Must continue to support fundraising and
project management skills
Partners worldwide
doing great work,
under difficult
circumstances,
with little support
Trauma Healing Initiative:
Cambodia
Building a culturally appropriate
healing
network
Carol White
The Center for Victims of Torture
Oct. 31, 2007
Project charge
To address the high levels of trauma in Cambodia
Poverty
Domestic violence
Community violence
and exploitation
Depression, alcohol
abuse, PTSD
What model to choose?
• Direct services with a training component?
• Training community mental health workers?
• Professional education?
• Support a torture treatment/human rights organization?
Project Context
• Currently one of the poorest
countries
• 80% of population engaged in
rural subsistence farming
• Trauma is a public health
problem.
– Older generation
– New levels of violence
• Rampant government
corruption & use of violence &
intimidation
Project Context
• Trafficking gangs practice sexual assault and other forms of
torture to enforce their control
• High levels of domestic violence can include torture (acid
attacks) Adequate mental health infrastructure to build local
professional capacity
Assets
•
•
•
•
•
At peace for over 15 years
Active civil society & many NGOs
Rapid economic growth
Strong family systems
A budding mental health infrastructure
A culture of impunity
• No legitimate war crimes trials
have been held since Pol Pot
times
• No truth and reconciliation
process
• Former Khmer Rouge & KR
victims live side by side; many
local officials are former KR
• Land-grabbing & other problems
with rule of law
• After 30 years a tribunal has now
been authorized, to last 3 years &
prosecute up to 6 top leaders,
starting in 2007
Exhumed skulls from the
“killing fields”
The model we chose
Trauma Healing Initiative
Strategy
1.
Training of trainers
2.
Community outreach &
education strategies
3.
Training the Network
4.
Network model development
Steps in the planning phase
Our first challenge:
Setting the stage
• Is it feasible? Do people want it?
• How can we position the project to get the
broadest support?
• Who should lead the effort in Cambodia?
Feasibility assessment
• Met with 20 organizations
• 30 key informants
• Explained project concept
Mapping networks of support and healing for
communities affected by torture
War crimes
documentation
Media for
public
education
Local health
NGOs &
village health
workers
Schools
Spiritual
healers
Public clinics
& hospitals
Traditional
healers
Human rights
environment
War crimes
tribunal
Community
leaders &
community
support
Trauma survivor,
family &
communities
International
health NGOs
Training
institutions
Ministry of
health
Human Rights
NGOs
Get National Program for Mental Health
congruence & blessing
• Dr. Ka Sunbaunet,
Director
• 20 year mental health
plan
• Interest in
participating
• Congruent with plan
Assess relevance to upcoming Khmer
Rouge trials (ECCC)
• Royal Government of
Cambodia task force
• Helen Jarvis, special
advisor
Choose implementing partner
• TPO Cambodia
– MOU/subgrant
– scope of work
– Hire coordinator
And the partner
chooses us.
Bring potential core group agency
leaders together for the “call”
Our next challenge:
Engaging partners in the project
• Engage individual
clinicians
• Get buy-in from
agencies
• Build knowledge &
trust in CVT & among
individuals
Engagement tactics
• International training
events
• Start regular meetings
to share cases &
decide training topics
• Help review project
plan
• Social time
A core group of clinicians begins to
meet monthly from 9 organizations
•
•
•
•
•
•
•
Trafficking victims
Human rights/torture clients
Extreme domestic violence/rape clients
Government psychiatry
University psychology department
Children’s mental health
Community mental health/training/trauma
treatment
• Khmer Rouge anti-impunity & documentation
• Cambodian returnees from the U.S.
Progress in the implementing
phase
The next challenge: How to train the
Core Group of Clinicians
Expert trauma training consultant living
in-country for one year
• In-depth training in
psychotherapy(150
hours to date)
• Case consultation &
observation
• Agency consults as
requested
• Pilot curricula for
future maualization
The next challenge: How to sustain
and deepen the learning ?
• Create treatment and training manuals
• Continue expatriate consultant function as long
as possible
• Incent organizational experimentation & service
enhancement
• Encourage collaboration among partner
agencies
Examples of collaboration among
partners
• Department of psychology
• National Program for Mental Health
• NGO requests for assistance
• 5 requests for service enhancement
subgrants
By the end of four years, THI hopes
to have:
• Trauma treatment and training manuals
• Piloted public education strategies
• A core group of multi-disciplinary Cambodian
clinicians who can train others
• Piloted innovations in ongoing clinical supervision
and training
• A trauma clinic functioning in Phnom Penh that
cares for torture survivors and serves as a training
site
By the end of four years, THI plans
to have:
• A functioning network of agencies and individuals
in one urban and one rural area.
• Ongoing relationships between clinical providers
serving torture/trauma survivors and human rights
organizations concerned about prevention of and
accountability for these abuses.
• A means of tracking and evaluating the level of
impact the network is having on reaching and
serving the target population.
Overall challenges with this model
of capacity-building
• Low control vs. buy-in & low cost
• Potential for high impact &
sustainability—but
• High risk for failure
• How can technology help in low
resource/tech savvy environment?
• Is there a “tipping point” when local
agents continue to collaborate and
train on trauma treatment ?
Opportunities:
a brighter future for Cambodia !
Guidelines for International Training in MH & Psychosocial
Interventions
For Trauma Exposed Populations in Clinical and Community
Settings
Weine, S., Danieli, Y., Silove, D., van Ommeren, M., Fairbank, J., & Saul, J.
Values
-Respectful
-Scientific
-Legitimacy of
multiple
perspectives
-Open dialog
-Integrating
differing
perspectives
Contextual
Challenges
-Culturally sensitive
-Entering insecure
environments
-Needs of all
subgroups considered
-Integrated with
development efforts
-Address short & long
term challenges
-Transparent
-Uses public health
principles
Core Curricular
Training Elements
Monitoring &
Evaluation
-Listening & communication
skills
-Assessment
-Interventions to diminish
distress
-Understand local context
-Problem solving strategies
-Treat unexplained somatic
pain
-Ongoing supervision
structure
-Covers self care
-Training include
monitoring / eval.
-Identify objective
w/ needs assess.
-Identify process
indicators
-Indicators to
evaluate impact on
trainees skills, on
services, and on
beneficiaries.
-Use appropriate
approaches
-Report / dissem.