Addressing Human Rights Violations - Springer Link

5 Addressing Human Rights Violations A Public Mental Health Perspective on Helping Torture Survivors in Nepal MARK VAN OMMEREN, BHOGENDRA SHARMA, DINESH PRASAIN, and BHAVA N. POUDYAL

BACKGROUND In 1990, the Centre for Victims of Torture Nepal (CVICT) was established to provide medical services to native Nepalese who were tortured during or before Nepal’s 1990 people’s movement that led to multi-party democracy. The initial assumption was that that there would be no more torture in a democratic Nepal, but this assumption proved to be naive. Torture resurfaced after the 1991 parliamentarian election as a means of controlling activists from opposition parties. Non-political torture—i.e., torture of suspected criminals during police investigation—never stopped. Thus, since 1991, CVICT has worked against continuing torture in Nepal. CVICT defines torture as: Intentional infliction of severe physical or mental suffering by the state’s law enforcing institutions or armed opposition on a person under the physical control of the perpetrator, for any reason (Van Ommeren, Sharma, & Prasain, 2000).

In 1991, when large numbers of Nepali-speaking tortured Bhutanese refugees entered Nepal, CVICT organized services. Between 1994 and 1997, CVICT ran a community-based rehabilitation program providing medical and psychosocial care for tortured Bhutanese refugees. These Nepali-speaking Bhutanese refugees were forced to leave southern Bhutan to escape persecution 259

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from the Bhutanese authorities, who appear to have feared a pro-democracy movement led by the Nepali-speaking population (Hutt, 1996). Since 1996, Nepal’s human rights situation has worsened, because of a spreading armed Maoist movement, which has resulted in an indiscriminate, hard-line government reaction. Between February 1996 and December 2000, 1396 people have died because of this insurgency (Informal Sector Service Centre, 2001). Most of the 909 people killed by the police were innocent villagers branded by the government to be Maoists. These villagers were murdered during alleged Maoist attacks. The Maoists themselves are estimated to have killed 234 policemen and 253 civilians (Informal Sector Service Centre). Maoists are also torturing political opponents within and outside their party, applying similar techniques as those used by the police. CVICT, an independent nongovernmental organization (NGO), treats people who have been tortured by the police, army, forest guards, or armed Maoist opposition. The aim of this paper is to analyze the activities of CVICT from a public mental health perspective. We will cover four areas: (a) population-based studies on torture survivors living in Nepal, (b) clinic data on help-seeking native Nepalese torture survivors, (c) care of Bhutanese refugee torture survivors and training of Bhutanese refugee counselors, and (d) care of native Nepalese torture survivors and training of native Nepalese counselors. For the purpose of this paper, we use the term native Nepalese to refer to a person who is born in Nepal and has Nepalese citizenship.

POPULATION STUDIES ON TORTURE SURVIVORS LIVING IN NEPAL Torture: How Common?

A public health perspective on torture calls for data on the percentage of torture survivors for a given population. Reliable estimates of the number of native Nepalese torture survivors have not been available. However, evidence exists that torture has occurred in Nepal throughout history (Guragain, 1994). State-sponsored torture was widespread during Nepal’s autocratic Panchayat regime (1962–1990). The Nepal Medical Association has estimated that more than 5000 people were tortured during the people’s movement for democracy in the spring of 1990 (Forum for Protection of Human Rights, 1991). On the basis of contacts with survivors and policemen, CVICT believes that routine torture occurs in every police station in Nepal. Our national survey conducted between 1994 and 1997, covering all prisons and an estimated 95% of all prisoners in Nepal, indicates that 70% of prisoners reported a history of physical torture that had occurred most often in police custody. Recently, in the context of the Maoist

HELPING TORTURE SURVIVORS IN NEPAL

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insurgency, the police have severely beaten and threatened the majority of people in specific villages accused of supporting Maoists. CVICT has been able to estimate the percentage of people with a history of physical torture among the Bhutanese refugees in camps in Nepal. In 1994, CVICT in cooperation with Bhutanese political parties and human rights organizations, collaborating agencies, and ex-patients, identified and registered 2331 survivors of physical torture in the camps. The identification process involved a hut-to-hut survey. By the end of 1994, there were 85,078 refugees in the camps, implying a history of self-reported physical torture among 2.7% of the refugees (Shrestha et al., 1998).

Population Mental Health Data When discussing a social problem such as torture from a public health perspective, it is important to look at population data of health consequences— which requires representative samples. Globally, most data sets on health consequences of torture are not representative, because the data have been collected from the select group of mostly Asian and African refugees who managed to escape to the West. However, the vast majority of the world’s torture survivors live in low-income countries. Until recently, representative data from populations of torture survivors have not been available. CVICT—in collaboration with the Amsterdam-based Transcultural Psychosocial Organization—has conducted two population-based mental health surveys among torture survivors in the Bhutanese refugee camps in Nepal. Because of the existence of a register of torture survivors in the camps, random sampling was possible. The first of the two surveys occurred in 1995 and focused on symptomatology. The results indicated that tortured Bhutanese refugees, compared with nontortured Bhutanese refugees, are, as a group, at increased risk of physical complaints and symptoms of anxiety, depression, and posttraumatic stress disorder (PTSD) (Shrestha et al., 1998). The second survey was conducted in 1997 and focused on diagnosed ICD-10 psychiatric disorders (Van Ommeren et al., 2001). The survey compared a representative sample of 418 tortured Bhutanese refugees with 392 nontortured Bhutanese refugees using face-to-face structured diagnostic interviews. The tortured Bhutanese refugees were more likely to report recent (within the previous 12 months) ICD-10 PTSD, dissociative (amnesia and conversion) disorders, and persistent somatoform pain disorder. In addition, the tortured refugees were more likely to report having had one of the following disorders at one point in their life: PTSD, dissociative (amnesia and conversion) disorders, persistent somatoform pain disorder, affective disorder, and generalized anxiety disorder. The data indicate that the differences between tortured and nontortured refugees in terms of rates of affective and generalized anxiety disorder disappear over

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time—implying that affective and generalized anxiety disorders are not chronic for most refugees with these disorders. However, lifetime rates of dissociative (amnesia and conversion) disorders and persistent somatoform pain disorder were similar to 12-month rates, indicating that these reported disorders have a chronic course in this population. Furthermore, even though men were more likely to report torture, tortured women (compared to tortured men) were at higher risk for most disorders (Van Ommeren et al., 2001). Both surveys are limited because concurrent validity (agreement with another criterion) has not been established. Nevertheless, the research has strengths in terms of content validity (relevant content), semantic validity (adequate translation), and technical validity (concern for response set issues) (Van Ommeren, 2000). Generalizability of Mental Health Findings The generalizability of our research findings to other populations of torture survivors is unknown. Research reviews indicate that results of psychiatric epidemiological surveys among refugees vary enormously (Boehlein & Kinzie 1995; Marsella, Friedman, Gerrity, & Scurfield, 1996). We ourselves have also been confronted with different findings of different studies on the same population. Psychiatric epidemiological data are extremely sensitive to variations in methods used to collect data. Moreover, because of cultural and language differences, responses to questions cannot be assumed to be comparable across cultures (Malpass & Poortinga, 1986; Van Ommeren et al., 1999). For these reasons and the aforementioned difficulty of obtaining random samples, the state of knowledge about the exact prevalence rates of disorders among populations of torture survivors is still very much limited. For example, we do not know to what extent the results of the studies among Nepali-speaking Bhutanese refugees generalize to native Nepalese torture survivors. Nevertheless, to the extent that our data are generalizable, our population-based research suggests a need to pay attention to PTSD, (medically unexplained) persistent pain, and (somatoform) dissociative disorders among torture survivors. Even in the West, treatment outcome researchers still have not identified empirically-supported effective treatment for the latter two disorders (Chambless et al., 1996). Treatment outcome research for complaints related to these disorders is needed. A limitation of assessing disorders in terms of international classification systems, such as the ICD-10, is the possibility of missing local categories of distress (Kleinman, 1977). In 1997, among the Bhutanese refugees, an epidemic of medically unexplained illness ("mass hysteria") occurred, involving fainting and dizziness. Our research shows that history of trauma was one of the predicting factors that placed people at risk during this epidemic (Van Ommeren et al., in press). Thus the finding that trauma is a risk factor for mental health may generalize beyond ICD or DSM disorders into local illness categories.


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CLINIC DATA ON HELP-SEEKING NATIVE NEPALESE TORTURE SURVIVORS Demographic Information

In 1999, 680 torture survivors were treated at CVICT clinics. Out of 680, 407 (60%) were native Nepalese torture survivors who sought help from CVICT for the first time. Of 407 new clients, more men (n = 324; 80%) than women (n = 83; 20%) sought help from our services. Eighteen (4%) were younger than 15 years and 21 (5%) were older than 60 years. The vast majority (n = 368; 90%) were between 15 and 60. CVICT has three clinics. The main clinic is in Kathmandu and the two subcenters are in Biratnagar and Nepalgunj, respectively in East and West Nepal (see Figure 1). Each of the three clinics received between 130 and 140 clients in 1999. The clinics did not vary much in terms of age and gender distribution of clients. However, the 3 clinics differed in terms of ethnicity of its clientele. While the clinic in Kathmandu treated mostly high caste Hindus living in the hills (n=109; 79%), the clinic in Nepalgunj treated mostly people belonging to the ethnic groups living in southern Nepal (n = 100; 75%). The client population at the clinic in Biratnagar was more evenly distributed in terms of ethnicity.

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Torture Experience and Presenting Complaints Almost all of the torture was reported to have been perpetrated by Nepal’s police and army. However, in Nepalgunj, 32 people (24%) and, in Kathmandu, 12 people (9%) reported having been tortured by Maoists. The three most common forms of torture reported by the 407 survivors are beatings on various body parts, verbal torture (e.g., threats), and deprivation (e.g., insufficient food). The torture inflicted by police on accused Maoist-leaders has been particularly brutal in terms of number and types of techniques. Most of the complaints reported by help-seeking Nepalese native torture survivors involve somatic pain. If we define a prevalent complaint as one that is presented by more than 10% of the clients, then more than half (n=7) of the 13 prevalent complaints in 1999 concerned somatic pain (Center for Victims of Torture Nepal, 2000). Many somatic pain complaints among our clients remain medically unexplained after examinations and investigations. The frequent presentation of medically unexplained (psychosomatic, functional) complaints may be because of a variety of reasons: Limited knowledge about the body’s functioning and belief that the body has been damaged leads Nepalese survivors to attribute any pain to torture (Sharma & Van Ommeren, 1998). Also, many local people are not aware that help can be offered for mental distress. Common beliefs are that mental distress, in contrast to bodily distress, is not serious unless you’re mad (i.e., display psychotic behavior) and that one should be strong enough to deal with mental distress. In addition to pain, survivors often present affective symptoms and vegetative symptoms (such as sleep disturbance, loss of appetite, and weakness) (Center for Victims of Torture Nepal, 2000). Interestingly, in contrast to what one would expect from our population-based research findings, simultaneous presentation of PTSD re-experiencing, avoidance, and hyperarousal symptomatology is not often identified in the clinic. As we will argue next, this may be because CVICT does not systematically check for PTSD symptomatology for every client who seeks help. Rather, so far, emphasis has been given to the symptoms that are most meaningful to the client—which tend to be somatic symptomatology. The absence of help-seeking through presentation of PTSD symptomatology may be interpreted as meaning that the PTSD concept has little relevance (i.e., low content validity) to the mental health of Nepalese torture survivors. However, our interpretation is as follows: Help-seeking behavior is likely influenced by expectations of help available, and help-seekers who do not expect treatment to be available for a certain symptom (e.g., anxiety) are unlikely to present that symptom. Moreover, as mentioned above, if people focus on the somatic aspects (such as body pain) of a psychosocial problem (such as traumatization), they are less likely to present psychological aspects (such as anxiety) even though they may experience much psychological distress. Considering that


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substantial PTSD rates have been identified in various cultures (Marsella et al., 1996) and not withstanding cultural variations (Marsella et al,), we believe that PTSD is a relevant concept for transcultural research and practice. Nevertheless, so far, in our clinic, our focus has been on presenting complaints, which typically are somatic complaints by survivors who focus on and expect treatment for somatic complaints. We are currently planning to conduct a study to identify the prevalence of PTSD symptoms among help-seekers who present somatic complaints only.

STRUCTURING SERVICES FOR TORTURE SURVIVORS In this section, we will describe (a) the structure of CVICT’s previous community-based health service for tortured Bhutanese refugees, (b) the training and supervision of Bhutanese refugee counselors, (c) the structure of CVICT’s current health services for native Nepalese torture survivors, and (d) the training and supervision of native Nepalese counselors.

Structure of Community-Based Project in The Bhutanese Refugee Camps Background. CVICT became initially involved with the Bhutanese refugees in 1991, when most of the refugees arrived from Bhutan. At that time, CVICT organized and provided emergency medical care for refugees settling haphazardly at the banks of two large rivers in eastern Nepal. Because of observations made during medical missions, CVICT felt the need for specialized treatment for torture survivors, including women raped by Bhutanese soldiers or police. In 1992, CVICT launched a program to support female torture survivors and selected female volunteer helpers from among the refugees. These volunteers were trained in basic communication and counseling skills and in maintaining confidentiality. The women worked through informal channels, going from hut-to-hut to identify and befriend the torture survivors. These volunteers were supported by counseling supervisors, social workers and medical personnel from CVICT. The volunteers’ main task in the initial stage was to serve as a link between existing facilities and persons in pain. One advantage of this approach was that the volunteers, being Bhutanese, shared a similar background and could, therefore, better relate to clients than would be possible for native Nepalese helpers. Furthermore, these Bhutanese refugee volunteers were readily available in the camps. As of January 1994, an integrated community based program for both male and female torture survivors was initiated. Male and female community health

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workers (CHWs) were hired and trained in listening and problem-solving skills, relaxation exercises, and yoga. A monthly medical clinic, which included a female doctor for female torture survivors, was organized with the help of the volunteers and some Bhutanese human rights organizations. The cases that were too difficult to manage at the camp level were referred to CVICT’s clinic in Kathmandu, which is a 1-day bus trip from the camps. The monthly medical clinic program, however, posed two drawbacks: (a) they served only a few people at a time, and (b) the expense was high.

Community-Based Rehabilitation Program. In March 1994, on the basis of repeated requests by refugee organizations, CVICT signed an agreement with the United Nation High Commission of Refugees (UNHCR), the agency responsible for the Bhutanese refugee camps, to become an implementing partner and start a community-based rehabilitation program for torture survivors. Within the UNHCR-coordinated aid structure, CVICT was given the responsibility for the care of all torture survivors in the camps. The program consisted of 1 doctor (who also served as local project director), 2 counseling field supervisors (1 nurse-counselor and 1 psychologist [B. N. P.]), a health assistant (i.e., a paramedical worker) for each of the 6 camps, and 30 CHWs. Except the doctor and psychologist, all CVICT field staff were Bhutanese refugees. CVICT used the following case management procedure in the camps: Help-seeking torture survivors were either referred to CVICT by community leaders or were identified by a CHW. A trained staff member, either a CHW or a supervisor, then completed a screening format that included identification of the patient, history, and presenting problems. After screening and documentation, the case was presented to the team, including community health workers, a health assistant, a counseling field supervisor, and the doctor. The team jointly assessed the case. On the basis of this assessment, the case was subsequently managed in the camps. The CHWs would usually provide counseling. The doctor visited each of the camps approximately one day a week and was responsible for general medical care and prescription of medication. The health assistants treated minor medical problems and monitored medication. Professional assistance from a consultant psychiatrist was sought every month for the treatment of cases with complex or severe psychiatric disorder. As before, difficult cases were referred to the CVICT clinic in Kathmandu or to hospitals for investigation, management, or both. On the basis of need and availability, some torture survivors were sent for participation in skills development and income generation programs, organized by two NGOs, namely, Oxfam UK and Bhutanese Refugee Aid for Victims of Violence (BRAVVE). By April 1997, CVICT had provided treatment to approximately half of the 2,520 Bhutanese refugees torture survivors. The other half never sought help. By 1997, the caseload had decreased to about 200 clients seeking CVICT


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services. The UNHCR asked CVICT to hand-over the 200 service seekers to be cared for through the existing basic medical facilities provided by Save The Children Fund United Kingdom (SCF-UK; also an implementing partner NGO of the UNHCR). To facilitate the hand-over, CVICT provided a ten-day counseling training to the SCF-UK health staff. As we shall argue later, in hindsight, we believe that the impact of our training was limited, because of the lack of proper follow-up supervision.

Training and Supervising Bhutanese Refugee Paraprofessionals Training of paraprofessionals is becoming one of the main components of psychosocial programming for traumatized people in low-income countries. Teaching basic psychosocial counseling skills is challenging, because these basic skills are, for a large part interpersonal skills (e.g., active listening, attending, responding with empathy, probing, encouraging, self-disclosure, brainstorming, focusing, challenging) (Egan, 1994-). Even though it is easy to explain the basic counseling process, instilling good long-term counseling habits is much more difficult. As is well-known among counseling and psychotherapy educators in the West, regular and thorough supervision is necessary to ensure lasting effects of training. However, when counseling training takes place outside the West, the supervision component is typically neglected. In this section, we will discuss CVICT’s efforts to train Bhutanese refugee professionals. A recurring theme is the observation that counseling skills are only gained after field supervision. CVICT provided a combined six weeks of training in 1994 and 1995 to the CHWs and health assistants. The training for CHWs primarily focused on counseling skills, mental health, first-aid, relaxation, and case discussions. The training for health assistants focused on mental health as well as general and forensic medicine. All staff underwent an orientation on human rights and local law. The six weeks of training was not enough to instill basic counseling skills in the paraprofessionals, because most trainees had difficulties refraining from advising, lecturing, suggestive questioning, and communicating their own explanations for clients’ problems. However, after the training, it was easier for the field supervisors to show and teach paraprofessionals how to counsel. As part of its ongoing collaboration with the Transcultural Psychosocial Organization, CVICT conducted another training program for the same group of CHWs and health assistants in 1996. This training was based on the WHO/ UNHCR manual Mental Health of Refugees (De Jong & Clarke, 1994). A core group of CVICT staff consisting of doctors, counselors, social workers, and psychologists studied the manual. Irrelevant parts of the manual were adapted or deleted. Subsequently, the manual was translated into Nepali by CVICT’s consulting psychiatrist, Dr. N. M. Shrestha. On the whole, the manual was perceived by the core group as a very useful resource for community workers, because the

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manual is simply written and covers core content. Adapting the training to the paraprofessionals’ level and using multiple role plays, however, appeared essential to ensure learning of core content. The ten-day training program for CHWs covered the content of the manual: basic listening skills, problem solving, stress management, progressive relaxation, managing functional complaints, understanding and treating mental illness and alcoholism, collaborating with traditional healers, problems of refugee children, and helping torture and rape survivors. The training was conducted for groups of 20 to 25 people at one time. Though the total program covered 10 days, it was split into two 5-day sessions with two weeks in between sessions. This split enabled the participants to use what they had learned during the first five days and then come back for the second part with that experience. During the training, it became clear that the use of technical words confused participants. Explaining the terms using local idioms, metaphors and local situations increased understanding. Most classes focused on group activity and sharing in order to make learning interesting and help the facilitators understand what the participants were learning. After the training, the facilitators felt that classes of 25 people had been too large. Moreover, although ten days was sufficient to cover all information, it was not sufficient to instill the counseling skills necessary to implement the new knowledge. As mentioned earlier, field supervision after training is the essential ingredient to develop such skills. The two counseling field supervisors, the nurse-counselor and the psychologist, visited each of the camps at least once a week and supervised the health assistants and CHWs. The supervisors checked all the individual records of clients. The supervisors also observed counseling sessions and provided the CHWs with suggestions to enhance skills. During these supervision visits, the GHWs were also encouraged to present cases and to debrief. This mode of supervision provided an environment in which the GHWs could learn from colleagues and, as far as we could tell, it was quite successful in increasing the skills of motivated CHWs. Nevertheless, not all CHWs were motivated or dared to show their weaker sides. It was a continuous challenge for supervisors to instill comfort about being supervised. The CHWs’ educational background ranged from three to ten years of formal education. The more educated CHWs were easier to train but had a tendency to seek and find better paying jobs outside the project. It was found that although previous education was important for the training of more abstract concepts, the most important factors were sensitivity and motivation. Indeed, one of the best-performing CHWs only had a Grade three education. As mentioned above, in the context of handing-over the project to SCF-UK, the aforementioned training of the manual Mental Health of Refugees was also provided to the 117 primary health care refugee paraprofessional staff of SCF-UK. However, in hindsight we are less satisfied with the results of this effort. After the


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training, supervision was very difficult to arrange, because the trainees were not staff of our organization, and SCF did not have the capacity to provide necessary supervision. Although we did have several large follow-up/supervision meetings after the training, CVICT was not able to give individual field supervision. Without follow-up supervision, counseling training can waste time and resources.

Structure of Current Health Services for Native Nepalese Torture Survivors Barriers to Access to Services. Most of Nepal’s injured or distressed native torture survivors do not seek help for a combination of reasons. First, those torture survivors who are threatened by the police do not feel safe enough to talk about what happened. Second, as mentioned above, since there is no custom to seek help for mental distress other than from traditional healers, survivors are likely to seek help only if they experience physical distress. Third, Nepalese police usually release survivors only after obvious wounds have healed. Fourth, due to mountains and poverty, the country has an extremely poor infrastructure, which inhibits access to health care services. (A Nepalese who lives in the remote mountainous regions may take five days by foot and a day by bus to reach an urban area with modern health care facilities. Moreover, during the monsoon, landslides hinder movement.) Fifth, modern health care services are considered expensive, and the existence of free treatment at CVICT is not known to most torture survivors. Sixth, many Nepalese torture survivors experience stigma about having been in contact with police (Besch et al., 2001) and therefore may feel inhibited to seek help. The Clinics. As mentioned in the introduction, CVICT has been providing medical and psychosocial services to torture survivors and their families since 1990. The main CVICT clinic is situated in Kathmandu. CVICT has currently two regional clinics in eastern and western Nepal, respectively (see Figure). These sub-centers provide general medical care and counseling for local survivors. As with the Bhutanese refugees, complex cases are referred to the Kathmandu clinic. The Kathmandu clinic has simple medical diagnostic facilities, counseling rooms, physiotherapy, and a separate room for relaxation exercises. There is no shelter for the survivors. Torture survivors get information about the clinic through human rights activists and organizations, political parties, human rights fact-finding teams, people who participated in training organized by CVICT, CVICT mobile clinics, CVICT’s nation-wide bulletins, and, especially, through previous clients. The majority of clients come from outlying districts, reaching the clinic after a very long journey, involving a lengthy bus journey, sometimes a few days of walking, or occasionally both.

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CVIGT aims to create a warm and safe environment at its clinics. Display of medical devices is minimized in the doctor’s room to avoid possible reminders of torture. Also, there are no pictures or drawings of torture in the clinic. The counseling rooms are comfortable with glass to allow clients to see outside the room. To build trusting relationships and to avoid unnecessarily reminders of the torture, no uniforms are allowed, i.e., none of the doctors wear white coats. (Although torture by doctors is uncommon in Nepal, doctors have been accomplices in terms of manufacturing records.) Staff are trained to respect all clients. Considering the torture and Nepal’s enormous class and caste distinctions, providing respect is very important. Although survivors can refer themselves to CVICT, CVICT has recently started to ask for supporting documents or referrals from known persons to prevent misappropriation of services. However, enough flexibility exists so that services are not denied to apparent genuine survivors who lack supporting documents. Case Management in the Clinics. As with the Bhutanese refugees, CVICT uses a casework model to help native torture survivors. On arrival, a patient is assigned to one counselor (i.e., a psychologist, a social worker, or a nurse or health assistant trained in counseling) who takes responsibility for the case. An initial interview is then held during which the client is told about CVICT and what it offers. The counselor subsequently documents demographic information and the history of imprisonment and torture. To reduce potential stress for the client, the information is sometimes documented over various sessions. At intake, clients are not pressured to tell all the details of the torture. The counselors inquire about accommodation and food and check whether the client feels physically safe in Kathmandu. Financial support for meals is provided to those who need it, and contact is made with concerned organizations to house those in need. Each client undergoes extensive physical examinations. A counselor is usually present during the doctor’s investigations and plays an active role in planning and implementing treatment. When necessary, clients are referred for more tests to nearby hospitals. For those with medical and psychosocial problems, counseling is carried out alongside the medical treatment, with the client coming in for various sessions. Occasionally, when clients need to be hospitalized, counselors and volunteers regularly visit and hold consultations with doctors and nurses. At CVICT, physiotherapy is offered when deemed useful. Short-wave diathermy has been found useful in terms of treating joint and muscle problems of clients. As with the treatment of Bhutanese refugees, CVICT’s consultant psychiatrist provides care for clients with severe mental disorder. Most of such clients


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want and receive medication. Moreover, CVICT gives emotional support and information to their families. In the future, CVICT hopes to organize training and supervision in brief family therapy for its counselors. Currently most of the counseling service provided at CVICT is individual counseling. Counseling. Long term psychotherapy is typically impossible because most clients are farmers from afar and cannot stay for treatment for a long time. Hence, counselors see clients with psychosocial problems as often as possible during the limited time that they are in Kathmandu, with an estimated average of two to three sessions during a 1-week stay. When the problem is more or less satisfactorily managed, clients often do not want to endure strenuous travel for a follow-up visit. Nevertheless, most clients do return when follow-up appointments are scheduled. Because of the clients’ short stay, the range of interventions that can be implemented is limited. Counseling at CVICT may be described as follows: Gaining Understanding of Illness Experience Before a decision can be made on how to help, the client needs to be understood from his or her perspective. Western textbooks often focus on the importance of assessment of psychopathology, presenting problems, the client’s current life setting, personal history, and family history. Even though all of these areas are important, at CVICT, the counselors are being encouraged to pay special attention to understand what medical anthropologists call illness experience (Kleinman, Eisenberg, & Good, 1978). Illness experience includes: (a) clients’ and community perceptions of the causes, nature, severity, and consequences of the illness (e.g., “Because of last year’s torture my blood vessels are broken, causing my leg to hurt. I will probably die because of my broken blood vessels. I am weak, I cannot work, and I am therefore useless. People in my village look down on me, because I am weak, and because I do not work”) and (b) reasons for seeking help and expected outcomes (e.g., “I traveled here to get pills for my broken vessels. The pills will heal my vessels but I will remain weak.”). Counselors are encouraged to use variations of questions phrased by Kleinman et al. to elicit illness experience, such as “What do you think has caused your problem? ... What do you think your sickness does to you? How does it work? ... What do you fear most about your sickness?” (p. 256). In addition, counselors use questions of our local adaptation of the Explanatory Model Interview Catalogue (EMIC; Weiss 1997), which was used during a recent study into illness experience among Nepalese help-seeking torture survivors (Besch et al., 2001). In short, the counselors are taught to use a basic medical anthropological approach to understand clients’ illness experience before proceeding to focus on problems and symptoms. Problem-Management Influenced by Lazarus and Folkman’s (1984) work, we distinguish between problem-focused coping (i.e., problem-solving) and problemimpact-focused coping (i.e., the problem situation cannot be reduced or resolved,

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but strategies can be devised to reduce the impact of the problem). We use the term problem-management for the process of working together with the client to identify and implement strategies for either (a) resolving or reducing the problem situation or (b) managing the impact of the problem situation. Torture survivors, once they are released from prison, often face many serious personal and social problems, such as unemployment, lack of income, social isolation, realistic fear of persecution, stigma of having been in jail, conflict within the survivor’s political party, changed relationships with family and community. These problems often lead to emotional and associated bodily distress. The Nepalese torture survivor will then present their medically unexplained somatic distress in the clinic, expecting medical intervention, such as medication, X-rays, or injections. Once the doctor considers the somatic distress to be without organic cause, the helper’s task is to see whether the somatic distress is accompanied by emotional distress that is caused by a problem situation in the client’s life. If a problem situation appears to be a contributing factor to the emotional and somatic distress, then counselors use a problem-management approach. Various problem-management approaches are available in the literature (D’Zurilla, 1986; Egan, 1994; Gath & Mynors-Wallis, 1997)—some of which have been shown to be effective in rigorous research in the West (e.g., Gath & Mynors-Wallis, 1997). CVICT counselors have been trained in Egan’s (1994)

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problem-management approach, a framework that emphasizes the flexible implementation of the following overlapping and interacting tasks: (a) helping clients identify, explore, and clarify their problem situations and unused opportunities, (b) helping clients identify what they want in terms of realistic goals that are based on an understanding of problem situations and opportunities within the sociocultural context, (c) helping clients develop strategies for accomplishing realistic goals, and (d) helping clients act on what they learn throughout the helping process through goal-accomplishing action. Attending, empathic listening, probing, challenging, and brainstorming are the core communication skills needed for successful implementation of this framework. This type of pragmatic framework has a distinct North-American flavor, especially when implemented in a linear manner (Ivey, Ivey, & Simek-Morgan, 1993). The framework is based on two assumptions that are widespread in modern western psychotherapy, namely, (a) systematic approaches to helping (e.g. therapy protocols) are beneficial, and (b) helping is most efficient if the helper aids the client in identifying and implementing ways of coping. Even though these assumptions are non-native, both Nepalese counselors and clients appear comfortable with this approach. Nevertheless, problem-management counseling can be enhanced through understanding of local ways of successful problem-management. Symptom Management To manage symptoms, the following four specific types of interventions are used at CVICT: (a) emotional support, (b) relaxation, (c) reattribution through education, and (d) exposure therapy. Emotional Support Emotional support involves mostly listening, empathy, encouragement, and communicating understanding of the clients’ feelings and point of view. Variations of aforementioned Kleinman et al.’s (1978) and Weiss’ (1997) medical anthropology questions are very useful to enhance understanding. During the earlier years of CVICT, emotional support was the main psychosocial intervention. Emotional support may lead to remoralization, resulting in reduced symptoms and relief of distress (Frank & Frank, 1991). Relaxation CVICT uses both western and traditional relaxation methods. Frequently used Western relaxation methods include progressive muscle relaxation, deep breathing, and guided imagery. Certain yoga asanas (postures) are used for low mood, while other asanas are used for back and pelvic problems reported by rape survivors. Of note, even though yoga is a Hindu construct, for many Hindu villagers, yoga is as foreign as progressive muscle relaxation. Reattribution through Education Reattribution through education (cf. Goldberg, Gask, & O’Dowd, 1989) has been useful when helping Nepalese torture survivors cope with medically unexplained pain. As mentioned before, the vast majority of medically unexplained pain is interpreted by clients as physical disease or injury (cf. Van Ommeren, Sharma, Makaju, Thapa, & de Jong, 2000). These interpretations are frequently the result of clients’ unsuccessful


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attempts to understand their body in terms of biomedicine. Once the CVICT counselors fully understand the details of their clients’ inaccurate medical explanations, the counselors rectify the clients’ misperceptions of biomedicine. Counselors do not use such reattribution approach for those clients who use spirituality to explain their body pain. In such instances, counselors try to discuss matters within the clients’ worldview (cf. Frank & Frank, 1991), providing emotional support and encouraging culture-sanctioned interventions, such as traditional healing and puja (worship). However, most clients report medical explanations rather than spiritual explanations, because most clients tend to consider CVICT as a health clinic where one is expected to present medical rather than spiritual problems. Second, client have access to traditional healers all over Nepal, and are likely to have already sought help from traditional healers if they have perceived a spiritual cause. It is not uncommon for clients to give multiple explanations for suffering, involving spiritual, sociopolitical, and inaccurate biomedical explanations. For example, a somewhat anxious male client may misattribute his stomach aches to broken nerves and cancer. Furthermore, he attributes me broken nerves to police torture, for which he blames a local politician who has left the area. He attributes his overall misfortune to having angered a God. Treatment may include: (a) a medical examination and relevant investigations followed by the good news that there is no serious disease or injury, (b) education that his nerves are not broken, (c) reattribution, i.e., explaining why many people experience stomach pain when feeling anxious, (d) emotional support for his feelings towards the local politician. Moreover, (e) the client’s perception of having angered a God is approached as a problem situation to be managed. After brainstorming for solutions, the client may decide to appease the God by visiting Pachupatinath, Nepal’s most holy Hindu temple in Kathmandu. Table 1 shows our guidelines for managing medically unexplained pain. Exposure-Based Interventions Treatments involving exposure are most likely to reduce trauma-related symptoms according to western treatment-outcome literature (Van Etten & Taylor, 1998). Counselors have been taught in the basics of Direct Therapeutic Exposure (De jong, 1994) but seldom implement this approach because clients come from afar and stay too short to start this involved treatment. Moreover, as we will discuss later, few clients are willing to engage in this therapy. For this reason, CVICT has interest in alternative approaches, which also include an exposure component. Alternative Approaches The counselors occasionally use two alternative interventions, particularly (a) Eye Movement Desensitization and Reprocessing (EMDR; Shapiro, 1995), which is a new approach involving a variety of procedures, including therapist-directed alternating sensory stimulation coupled with brief exposure of trauma memories and related associations, and (b) techniques based on energy psychology, which are highly alternative techniques based on

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the assumption that, by tapping on various body parts while focusing on the traumatic memory, one can undo emotional distress, which is assumed to be caused by an imbalance in hypothesized energy meridians in the body (e.g., Craig & Fowlie, 1997). Several GVICT helpers have been keen to apply these new techniques. These new approaches are interesting for work outside the West for various reasons. First, these approaches appear to deliver rapid relief. Rapid relief is expected by clients who often can only attend few sessions and who have been conditioned to expect rapid relief after treatment by shamans. Although CVICT has no long-term data on the efficacy of its use of these new techniques, they appear to facilitate therapeutic relationship building, rapid subjective relief of distress, improved sense of well-being, remoralization, and symptom reduction. Second, these alternative approaches involve physical actions (eye movements, hand tapping) that may be experienced as ritual. Local people have been conditioned to experience healing through combinations of animistic, Hindu, or Buddhist rituals (and through herbal and western medications), but they typically do not know or believe that healing may potentially occur through talking. Talking is not considered treatment by most people in Nepal: psychotherapy is for many an unknown construct. Third, the manuals of these approaches provide clear guidelines to counselors who often communicate discomfort with the ambiguity of conventional western counseling guidelines. Fourth, unlike many cognitive-behavioral therapies, these alternative approaches do not involve homework assignments. In our experience, most Nepalese clients are not interested in dierapy-related homework (cf. De Jong, 1999). Fifth, unlike cognitive therapy, these alternative approaches do not involve the difficult task of eliciting and challenging clients’ distorted thinking. Sixth, unlike exposure therapy, the client is not required to tell the details of the torture or to repeatedly relive the details of the worst moment of it. In our experience, clients are not easily convinced to talk about the details of their trauma because they neither understand nor agree that such conversation will give long-term relief. The strong cultural belief is that it is best not to try to think about painful memories. Seventh, paraprofessionals can learn these approaches easier than more complex conventional therapy. (Nevertheless, before learning these approaches, counselors need to have solid basic skills and substantial experience in helping trauma survivors.) Several CVICT counselors have been able to selectively apply these alternative techniques within a supportive and problem-management approach to helping. However, the techniques are applied very conservatively. So far, EMDR has almost only been used when the following three conditions apply: the client clearly wants treatment for PTSD re-experiencing symptoms, the client is emotionally stable, and the client is not leaving town within a day after treatment. Although such conservative approach leads to only occasional use, results appear consistent with EMDR’s overall very positive treatment outcome literature


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(Van Etten & Taylor, 1998). An EMDR protocol for pain management exists (Grant, 1998), and, CVICT will field test it in the near future.

Training and Supervising Native Nepalese Counselors The original native Nepalese counselors at CVICT include two nurses, a health assistant, and a social worker. After an initial training at the International Rehabilitation Counsel for Torture Victims in Denmark in 1992, they received a 1-week training by an Australian psychologist and a 2-week training by two American psychologists. As a result of these training occasions, the counselors adapted a person-centered approach to helping, emphasizing problem-management, relaxation, and, especially, emotional support. After this training, the counselors occasionally received additional training by a range of foreign mental health professionals who often used part of their holiday time in Nepal to train CVICT staff. In addition, counselors were able to attend a few short training programs abroad. Overall, the collective impact of this diverse training was very positive. By 1996, the CVICT counselors had developed into confident helpers with strong basic skills. Between 1996 and 1998, the Amsterdam-based Transcultural Psychosocial Organization stationed an expatriate mental health professional (M. V O.) in Nepal to uplift the care and conduct research at CVICT, focusing mainly on the Bhutanese refugees. As part of this community-based project, the native Nepalese CVICT counselors studied and adapted the WHO/UNHCR Mental Health of Refugees manual (De Jong & Clarke, 1994; see the Training and Supervising Bhutanese Refugee Paraprofessionals section of this paper). As a result, the helpers became highly familiar with the important content of this manual. During this time, the expatriate professional was a resource person for questions, and he introduced interventions (see the Counseling section of this paper). In 2000, the same expatriate professional returned to CVICT to focus on training and supervising native Nepalese counselors. This led to the development and implementation of a 4-month internship program to thoroughly train six native Nepalese counselors, who subsequently gained employment at CVICT. Five out of six counselors had been part-time Master of Arts-level clinical psychology lecturers at the local university but had not previously worked with clients. The 4-month internship consisted of four parts: (a) a 2-week psychosocial counseling pre-practice training at CVICT in Kathmandu, (b) six 2-week rotations at the three CVICT clinics and at two local NGOs, (c) daily 1.5 hour supervision at CVICT in Kathmandu for those stationed in Kathmandu during rotations, and (d) in between rotations, regular two-to-five-day meetings at CVICT in Kathmandu for supervision, feedback, and further training. Interns were trained in communication skills, problem-management counseling, resolving medically unexplained pain, helping children and adolescents,

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eliciting explanatory models and other illness experience, stress and coping, relaxation, and prioritizing problems. Moreover, the interns were trained in major mental disorders, suicide, trauma reactions, systematic desensitization for phobias, exposure therapy for trauma reactions, energy therapy techniques, and conducting focus groups. Focused lectures, minimal reading, numerous role plays, and extensive practice with clients involving daily supervision appear to have been a good combination to convert motivated, yet inexperienced Nepalese psychologists into competent helpers who can make a difference. Since September 2000, CVICT has held a routine of 1-hour clinicsupervision meeting at the end of each day. The daily meeting is an opportunity to discuss cases, including counselor’s emotional reactions to cases. During each meeting, a different staff member acts as the facilitator-supervisor. Guidelines for supervision have been drafted on the basis of our experience and on the literature (Shanfield, Matthews, & Hetherly, 1993). These guidelines are available upon request. The work of the counselors is difficult, because many of the problems have no resolution. The CVICT counselors’ ability to accept their limitations and cope with the challenges of their work appears strong. Currently, regular supervision and support seems to help them to remain focused and pragmatic. Nevertheless, during the last ten years, temporary burn-out has occasionally occurred, which may be related to factors that were present at those occasional times: (a) heavy case loads, (b) less than perfect relations among staff, and (c) counselors’ realistic fear of police. Although the counselors are certainly influenced by their work, thus far, we have not observed long-term vicarious traumatization among the staff.

PREVENTION

From a public health perspective, the obvious way to prevent the health sequelae of torture is to prevent torture itself through sociopolitical action. CVICT has a strong human rights agenda and has been involved in a variety of activities to stop torture in Nepal: CVICT has written the draft of the Torture Compensation Act, which has been accepted by Nepal’s parliament in diluted form. CVICT is currently lobbying for a stronger Torture Compensation Act. CVICT provides legal aid to torture survivors, which mostly focuses on obtaining compensation from the government for torture survivors. CVICT has been involved in successful public interest litigation, which has resulted in a Supreme Court order to the government to form a Human Rights Commission. Because of this and other pressures, the government formed a Human Rights Commission in 2000. Through numerous workshops and bulletins and through various media, CVICT has been involved in raising human rights awareness among the general public and among professionals from the fields of health, law, and


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education. CVICT currently chairs the Alliance of Human Rights and Social Justice Nepal, an alliance of major Nepali human rights organizations, and is thus involved in coordinating human rights activities. CVICT has been very active in facilitating penal reform, including training more than 90% of Nepal’s prison wardens in prison management with concern for prisoners’ rights. CVICT has been studying community mediation from a sociological perspective (Prasain, in preparation), and, on the basis of this research, a pilot project will start on facilitating community mediation in Eastern Nepal. CVICT organizes fact-finding missions to document torture and organizes international appeals for political prisoners and disappeared persons in collaboration with Amnesty International and the World Organization Against Torture (OMCT/SOS Torture). Finally, because violence is learned behavior and is common in Nepali schools, CVICT has developed a training program for teachers on non-violent forms of discipline. Thus, a focus on description and treatment of health sequelae of torture does not hinder meaningful action against torture and related social suffering. Providing health services to torture survivors is sociopolitical action in itself. Through providing services, CVICT communicates to the Nepalese government that their torture is noticed, and that people are working to undo its effects.

REFERENCES Besch, K., Van Ommeren, M., Poudyal, B. N., Jha, R., KC, R., Loksham, C., Pradhan, H., Regmi, S., Shrestha, S., & Sharma, B. (2000). Impact of torture: A pilot study of stigma and illness experience in Nepal. Manuscript in preparation. Boehlein, J. K., & Kinzie, J. D. (1995). Refugee trauma. Transcultural Psychiatric Research Review, 32,223–251. Centre for Victims of Torture Nepal (2000). Annual report 1999. Kathmandu, Nepal. Chambless, D. L., Sanderson, W. C., Shoham, V, Bennett-Johnson, S., Pope, K. S., Crits-Christoph, P., Baker, M., Johnson, B., Woody, S. R., Sue, S., Beutler, L., Williams, D. A., & McCurry, S. (1996). An update on empirically validated therapies. The Clinical Psychologist, 49, 5 –18. Craig, G., & Fowlie, A. (1997). Emotional freedom techniques: The manual. Novato, CA. Creed, F., & Guthrie, E. (1993). Techniques for interviewing the somatising patient. British Journal of Psychiatry, 162, 467–471. De Jong, J. T. V M. (1994). Helping victims of torture and other violence. In J. T. V M. De Jong, & L. Clarke (Eds.), Mental health of refugees (prepublication version) (pp. 147–159). Geneva: World Health Organization. De Jong, J. T. V M. (1999). Psychotherapie met immigranten en vluchtelingen [Psychotherapy with immigrants and refugees.] In T. J. Heeren, R. C. Van der Mast, P. Schnabel, R. W. Trijsburg, W. Vandereycken, K. Van der Velden & F. C. Verhulst (Eds.), faarboek voor psychiatrie en psychotherapie 1997–2000 (pp. 220–237). Houten, the Netherlands: Bohn Stafleu Van Loghum. De Jong, J. T. V M. & Clarke, L. (1994). Mental health of refugees (prepublication version). Geneva: World Health Organization. D’Zurilla, T. (1986). Problem-solving therapy: A social competence approach to clinical intervention. New York: Springer.

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Egan, G. (1994). The skilled helper: A problem-management approach to helping (5th ed.). Pacific Grove, CA: Brooks/Cole. Forum for Protection of Human Rights. (1991). Dawn of democracy: People’s power in Nepal. Kathmandu, Nepal. Frank, J. D., & Frank, J. B. (1991). Persuasion and healing: A comparative study of psychotherapy (3rd ed.). London: John Hopkins Press. Gask, L., De Jong, J. T. V M., & Sell, H. (1994). Functional complaints. In J. T. V M. De Jong & L. Clarke (Eds.), Mental health of refugees (prepublication version) (pp. 41–48). Geneva: World Health Organization. Gath, D., & Mynors-Wallis, L. (1997). Problem-solving treatment in primary care. In D. M. Clark, & C. G. Fairburn (Eds.), Science and practice of cognitive behaviour therapy (pp. 415–431). Oxford, England: Oxford University Press. Goldberg, D., Gask, L., & O’Dowd, T. (1989). The treatment of somatization: Teaching techniques of reattribution. Journal of Psychosomatic Research, 33, 689–695. Grant, M. (1997). Pain control with Eye Movement and Desensitization and Reprocessing: An information processing approach. Sydney, NSW. Guragain, G. (1994). Indelible scars: A study of torture in Nepal. Kathmandu, Nepal: Centre for the Victims of Torture. Hutt, M. (1996). Ethnic nationalism, refugees, and Bhutan. Journal of Refugee Studies, 9, 397–420. Informal Sector Service Centre (2001). Human Rights Year Book 2000. Kathmandu, Nepal. Ivey, A. E., Ivey, M., & Simek-Morgan, L. (1993). Counseling and psychotherapy: A multicultural perspective (3rd ed.). Needham Heights, MA: Allyn & Bacon. Kleinman, A. (1977). Depression, somatization and the new cross-cultural psychiatry. Social Science and Medicine, 11, 3–10. Kleinman, A., Eisenberg, L., & Good, B. (1978). Culture, illness, and care: Clinical lessons from anthropologic and cross-cultural research. Annals of Internal Medicine, 88, 251–258. Lazarus, A., & Folkman, S. (1984). Stress, appraisal, and coping. New York: Springer. Malpass, R. S., & Poortinga, Y. H. (1986). Strategies for design and analyses. In W. J. Lonner & J. W. Berry (Eds.), Field methods in cross-cultural research (pp. 47–84). Beverly Hills, CA: Sage. Marsella, A. J., Friedman, M. J., Gerrity, E. X, & Scurfield, R. M. (Eds.) (1996). Ethnocultural aspects of posttraumatic stress disorder: Issues, research, and clinical applications. Washington, DC: American Psychological Association. Prasain, D. (2001). Community level dispute resolution in eastern rural Nepal. Manuscript in preparation. Shanfield, S. B., Matthews K. L., & Hetherly, V (1993). What do excellent psychotherapy supervisors do? American Journal of Psychiatry, 150, 1081–1084. Shapiro, F. (1995). Eye movement desensitization and reprocessing: Basic principles, protocols, and procedures. New York: Guildford. Sharma, B., & Van Ommeren, M. (1998). Preventing torture and rehabilitating survivors in Nepal. Transcultural Psychiatry, 35, 85–97. Sharpe, M., Peveler, R., & Mayou, R. (1992). The psychological treatment of patients with functional somatic symptoms: A practical guide. Journal of Psychosomatic Research, 36, 515–529. Shrestha, N. M., Sharma, B., Van Ommeren, M., Regmi, S., Makaju, R., Komproe, I., Shrestha, G. B., & De Jong, J. T. V M. (1998). Impact of torture on refugees displaced within the developing world: Symptomatology among Bhutanese refugees in Nepal. JAMA, 280, 443–448. Van Etten, M., & Taylor, S. (1998). Comparative efficacy of treatments for post-traumatic stress disorder: A meta-analysis. Clinical Psychology and Psychotherapy, 5, 126–144. Van Ommeren, M. (2000). Impact of torture: Psychiatric epidemiology among Bhutanese refugees in Nepal. Doctoral dissertation, Vrije Universiteit, Amsterdam, The Netherlands. Van Ommeren, M., de Jong, J. T. V M., Sharma, B., Komproe, I., Thapa, S. B., & Cardeña, E. (2001). Psychiatric disorders among Bhutanese refugees in Nepal. Archives of General Psychiatry, 58, 475–482.


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Van Ommeren, M., Prasain, D., & Sharma, B. (2000). Defining torture. Manuscript submitted for publication. Van Ommeren, M., Sharma, B., Komproe, I., Poudyal, B., Sharma, G. K., Cardeña, E., de Jong, J. T. V. M. (in press). Trauma and loss as determinants of medically unexplained epidemic illness in a Bhutanese refugee camp. Psychological Medicine. Van Ommeren, M., Sharma, B., Makaju, R., Thapa, S., & De Jong, J. T. V M. (2000). Limited cultural validity of the Composite International Diagnostic Interview’s probe flow chart. Tmmcultural Psychiatry, 67, 123–134. Van Ommeren, M., Sharma, B., Thapa, S., Makaju, R., Prasain, D., Bhattarai, R., & De Jong, J. T. V. M. (1999). Preparing instruments for transcultural research: Use of a translation monitoring form with Nepali-speaking Bhutanese refugees. Transcultural Psychiatry, 36, 285–301. Weiss, M. (1997). Explanatory Model Interview Catalogue (EMIC): Framework for comparative study of illness. Transcultural Psychiatry, 34, 235–263.