assessing trauma in sierra leone
TRANSCRIPT
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Assessing Trauma inSierra Leone
Psychosocial Questionnaire: Freetown
Survey Outcomes by Kaz de ong!
"aureen "ulham! and Sas#ia van der
Kam
Ac#nowledgements
This report is the product of close cooperation
and hard work by a multinational team motivated
to bear witness to the anguish suffered by the
Sierra Leone population.
Warm thanks to MSF-olland!s medical
coordinator in Freetown" Maureen Mulham" for
skillfully guiding the survey process. Lo van #eers
was instrumental during the data entry process.Special thanks go to the group of Sierra Leonian
interviewers and their respondents for the difficult
and often painful work of asking and answering
the survey $uestions. For reasons of security" the
names of the interviewers%interviewees cannot be
given.
& 'a( de )ong" Mental ealth *dvisor" MSF-
olland +)anuary ,
$% Summary
This report is based on a mental health survey of
persons in Freetown" Sierra Leone in May /000.
Several months earlier the city saw fierce fighting
that left more than 1 people dead" an untold
number in2ured and mutilated" and tens of
thousands homeless. Many of those affected had
gone through similar e3periences before" and had
fled to Freetown for its relative safety.
The findings only touch on the sufferings of the
country!s population. The civil war in Sierra Leone
began in /00/ and no region has been spared.
The residents of Freetown were not alone in their
trauma4 the country!s town and village dwellers
too" have often been repeated victims of war"
displaced time and again from their homes and
sub2ected to terrible and long-lasting hardships.
*lthough fighting in the country has largely
ceased since the Lome 5eace *ccord of )uly
/000" the effects of that war will be with the
population for a long time. *s this survey makes
clear" few escaped the mental trauma of the war
(one that Freetown became for more than three
weeks in )anuary /000.
6octors Without #orders found" among other
things" that 007 of those surveyed suffered some
degree of starvation" 07 witnessed people being
wounded or killed" and at least 87 lost someone
close to them. The intensity of the fighting is
indicated by the numbers4 187 endured shelling"
1,7 the burning of their property" and 9:7 thedestruction of their homes. 5hysical harm was
also great4 97 had been amputated +typically a
limb" hand" foot or ear" /17 had been tortured by
a warring faction" ::7 had been held hostage"
and :07 had been maltreated in some way or
another.
The psychological impact of actually witnessing
horrific events imposes a serious psychologicalstress. 6eliberately or not" witnessing at least
once events such as torture +8;7" e3ecution
+;/7" +attempted amputations +:,7" people
being burnt in their houses +,
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traumatic stress. Traumatic stress associated with
physical complaints like headaches +:ven after hostilities cease" the warmay continue in people!s minds for years"
decades" perhaps even generations. To address
only the material restoration and physical needs
of the population denies the shattered emotional
worlds" ignores the broken basic assumptions of
trust and benevolence of human beings" and
leaves unaddressed the shattered moral and
spiritual conse$uences of war.
*fter severe conflicts" people seek to forget or
deny what happened to avoid painful memories of
the past and to escape the sense of
hopelessness" humiliation" and anger. #ut for the
direct survivors of violence" acknowledgement of
the suffering is a crucial element for making
sense of and addressing traumatic e3periences.
To help a traumati(ed person there is a need torestore the bonds between the individual and their
surrounding system of family" friends" community"
and society. ?vercoming the e3treme stress and
sometimes even severe mental health problems
associated with mass traumati(ation such as
occurred in Sierra Leone" tests the healing
capacity of family and community.
$$% &ac#ground
'% Political (onte)t
=n May /009" military officers of the self-
proclaimed *rmed Forces @evolutionary Aouncil
+*F@A overthrew the democratically elected
government of 5resident *hmed Te2an 'abbah
and formed a 2unta with the insurgent
@evolutionary Bnited Front +@BF. =n February
/00
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Leone" but because of the security situation" the
program was suspended. *fter the )anuary /000
events" 6octors Without #orders" through trained
local counselors" started psychosocial care to
amputees in the hospital in Freetown.
Bntil recently" emergency medical programs havebeen dominated by a perspective emphasi(ing
physical health and immediate relief. #ehavioral"
mental" and social problems were neglected.
Since the genocide in @wanda and the conflict in
the Former Eugoslavia" it has become recogni(ed
that mental health and psychosocial programs
can greatly contribute to the alleviation of the
suffering of people in war and disaster-stricken
areas +e.g. *2dukovic" /009. Focused primarily
on the effects of post-traumatic stress" these
programs have put the psychological
conse$uences of massive man-made violence on
individuals and populations on the agenda of the
international community.
@esearch has shown that nearly all war victims
e3perience recurrent and intrusive recollections"dreams" and sudden feelings of reliving the event
+e.g. #ramsen" /001. These responses are
combined with increased arousal" avoidance of
stimuli associated with the trauma" and numbing.
Through the oscillation between intrusions and
avoidance" the psychological integration of the
traumatic e3perience is reali(ed" which has been
made clear in cognitive processing models +e.g.
Areamer" /008. 5hysical symptoms such as
headaches" stomach pains" and back pains are
often part of this process. These physical
symptoms fre$uently cause persons to seek
medical attention. The occurrence of mass 5TS6
can have a debilitating effect on communities.
6aily e3perience in the field demonstrates that
traumati(ed people impede the restoration of
ordinary life and 2eopardi(e conflict resolution.
#esides the mental and physical suffering that
people e3perience" on a spiritual level their
fundamental assumptions of control and certainty"
as well as basic beliefs in the future and in the
benevolence of other people" are also shattered--
often beyond repair +)anoff-#ulman" /00, 'leber
G #rom" /00,. @esearch indicates that the
duration and the fre$uency of traumatic
e3periences negatively influences physical"
mental and spiritual coping mechanisms +e.g.
'leber G #rom" /00,.
5ost-Traumatic Stress 6isorder +5TS6 is
fre$uently used in connection with traumatic
events. The concept is well fitted to describe the
serious and prolonged disturbances of individuals
confronted with ma2or life events. The distinctive
criteria of 5TS6 +6iagnostic and Statistical
Manual of Mental 6isorders" ;th ed. +6SM-=H
*5*" /00; are +/ an e3treme stress" +,
intrusive and re-e3periencing symptoms" +:
avoidance and numbing symptoms" +; symptoms
of hyperarousal" and +8 symptoms of criteria ," :"
and ; should be present at least one month. The
concept is also included in the =nternational
Alassification of 6iseases +=A6-/ of the World
ealth ?rgani(ation +/00,. 5TS6 is strongly
associated with dissociation and somati(ation
+McFarlane" *tchinson" @afalowic( G 5apay"
/00; Han der 'olk et al." /001.
6octors Without #orders has been addressing the
psychosocial problems of the survivors of
violence in Sierra Leone before" during and after
the )anuary /000 events. 6octors Without
#orders is very concerned that neglect of the
mental health and psychosocial problems of the
large number of people who are suffering from
prolonged traumatic e3periences may cause
serious problems for the future of Sierra Leone.
Simply ending the war does not eliminate the
problem.
6octors Without #orders decided to start a
psychosocial program in Freetown. *s part of its
program" a population survey was conducted in
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Freetown to learn what people e3perienced" to
what e3tent the events resulted in traumatic
stress" and what other medical needs the
inhabitants had.
$$% "ethodology
'% Target Po+ulation , Sam+le
The survey was conducted after receiving the
permission of the appropriate authorities" during
the first two weeks of May /000" four months after
the atrocities in Freetown. #ecause everyone in
Freetown had been sub2ected to traumatic
e3periences" both =nternally 6isplaced 5ersons
+=65!s and residents were included in the
sample.
* two-stage cluster sampling method was used" a
methodology based on vaccination surveys. The
methodology is e3tensively described in the
various handbooks of W?. The sampling
method entails a first phase where : clusters are
chosen. =n the second phase a pre-set number of
individuals are chosen per cluster. The sampling
techni$ue itself ensures that every individual has
an e$ual chance to be chosen. The result
obtained through sampling techni$ues is an
appro3imation of the real value in the entire
population. The real population value is in a range
around the value obtained by the sampling
method. The narrower the range" the more
precise is the estimation.
The sample consisted of : clusters of F" which gives a population
of 1". The rural part of the Western area
+encompassing Freetown and its peninsula was
e3cluded because most of the area was not
accessible during the survey for security reasons.
The areas +clusters were chosen with a chance
proportional to the population si(e. The teams
went to the center point of these areas a pen was
spun to determine the direction and every tenth
house to the right was selected until the eight
necessary for the cluster had been identified. The
most senior member of the household present
was interviewed. *ny refusals were noted and the
selection process continued to the ne3t tenth
house. There was a note made on each
$uestionnaire of the displaced or resident status
of the interviewee. Where the cluster was in a
displaced camp one person from each section of
the camp was interviewed" depending on the
layout of the camp.
*% The $nterview
The counselors worked in pairs. *fter the
counselors introduced themselves and 6octors
Without #orders" the purpose of the survey was
e3plained to the potential participant. =n the
introduction it was clearly stated that the
participant would not receive any compensation"that the data were treated confidentially and that
the interview would last for a ma3imum of ;
minutes. *fter the introduction the participant
could decide whether to participate. The timing of
the interviews was crucial" since people had to be
at home and be available.
=t was important that the participants completed
the survey. To avoid e3ceeding the interview timeit was e3plained that direct and short answers
were necessary. >3tra discussions or
conversations were avoided. owever" the
counselors were permitted to stop or interrupt the
interview when they deemed the $uestions to be
too emotionally upsetting for the participant.
When the counselor believed that the participant
needed follow-up support" referral to professional
counselors was facilitated.
*ll teams had a daily technical and emotional
debriefing. Further emotional support for the
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counselors was provided through the 6octors
Without #orders psychosocial peer support
system for national staff" which was trained by the
6octors Without #orders *msterdam 5ublic
ealth 6epartment and 5sychosocial Aare Bnit.
-% The Psychosocial Questionnaire
The structured interview was based on a
$uestionnaire consisting of :8 $uestions with
subdivisions.
To control the time of the interview most
$uestions offered a limited number of alternatives
from which the participant could choose. ?nly two
$uestions in the health section of the
$uestionnaire were open ended. To limit the
emotional burden the $uestions were put as
factually and simply as possible. When unclear" a
short e3planation was allowed. 5articipants were
not allowed to fill the $uestionnaire later nor were
they permitted to study the $uestionnaire in
advance. =nterviewers had to respect
confidentiality at all times.
To assess the level of trauma" three important
indicators of traumatic stress were measured. The
first indicator is the presence of a potential
traumatic event. The second indicator is the
impact of event scale" which e3presses the e3tent
of traumatic stress response. The third indicator
appraises physical complaints" which likely are
correlated to traumatic stress. When all three
indicators of traumatic stress were positive" at
least strong circumstantial evidence for the
prevalence of traumatic stress was found.
The psychosocial $uestionnaire was composed of
four sections. The first section assessed the
demographics and personal background of the
participant. * second section appraised traumatic
events such as e3posure to violent situations"
who was lost and the traumatic events witnessed.
#oth the number of traumatic e3periences and
their length are important risk factors in the
development of 5TS6 +'leber G #rom" /00,.
The third section measured the impact of these
events. To measure the prevalence of traumatic
stress responses the =mpact of >vent Scale was
used +orowit(" Wilner G *lvare(" /090. This
psychometric instrument assesses two central
dimensions of coping with drastic life events4
intrusion and denial. =t has been used worldwide
and generally consistent structures have been
found across samples and situations The final
section of the $uestionnaire evaluated current
physical health complaints and needs. 5hysical
symptoms like headaches" stomach problems"
general body pain" di((iness or palpitations are
often e3pressed by people suffering from
traumatic stress. * high prevalence indicates a
possible high level of traumatic stress or 5TS6.
.% (onclusions
The survey among respondents from all suburbs
of Freetown indicates high levels of traumatic
stress among the population surveyed. >very
indicator +e3perienced events" =mpact of >ventScale and 5hysical ealth points in the same
direction. The indicators are discussed below.
The responses on the second section appraise
the traumatic e3periences of the respondents.
The high percentages of certain events
+starvation +007" witnessing wounded people
+07" having lost someone close +at least 87
result in a clear conclusion that most respondents
living in all parts of Freetown have e3perienced at
least one traumatic e3perience. =t is likely they
have been sub2ected to many more.
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The =mpact of >vent Scale +orowit(" Wilner G
*lvare(" /090 indicates high levels of traumatic
stress and 5TS6 in the survey population +007.
The final score on the =.>.S. is constructed
around two clusters of reactions4 intrusions +e.g.
flashbacks" reliving of events and avoidance +e.g.
evasion of situations" amnesia.
The outcome of the =mpact of >vent Scale +=.>.S.
is not conclusive and should be considered with
care since the =.>.S. $uestionnaire is not
validated for Sierra Leone and the cut-off scores
applied in this report are based on Western
>uropean data. The outcomes on the =.>.S.
should not lead to the conclusion that almost
everybody in Sierra Leone is traumati(ed and
suffers from 5TS6 or other mental health
problems. owever" the high scores on the =.>.S.
are supported by the outcomes on the appraisal
of traumatic e3periences +second section.
The results of the last section +physical health
confirm the tendencies reported earlier. Traumatic
stress associated with physical complaints +likeheadache +:07 and body pains +/,7 is
reported most fre$uently. The visits to health
facilities are relatively high +;,7.
The high levels of traumatic stress or even 5TS6
indicate a clear need for psychosocial or mental
health interventions to address the needs of the
survivors of violence in Freetown. To focus
humanitarian aid only on material restoration andphysical needs denies the shattered emotional
worlds of the population" and ignores the ruined
basic assumptions of trust and the benevolence
of human beings. =t leaves unaddressed the
broken morale of the survivors and the spiritual
conse$uences of war.
* population that is in general psychologically
healthy can prosper and overcome the burdens of
the past. 5sychologically healthy people can also
solve their disagreements in less violent ways.
elping traumati(ed people is a matter of
restoring the bond between the individual and the
surrounding system of family" friends" community
and society. To overcome mass traumati(ation as
in the case of Sierra Leone" the healing capacity
of family and community systems must support
people in their coping with e3treme stress and
more severe mental health problems.
5sychosocial and mental health programs are
evident tools in this process and should not be
overlooked. The involvement of Sierra Leoneans
in these programs is of crucial importance.
1. a) Which Sierra Leone citizens were
surveyed for this report?b) What were the major contributors
to (things that created) !S" in
#reetown and Sierra Leone
according to the $S# report?
%. &ccording to this report what is so
important for the direct survivors of
vio'ence and sufferers of !S"?
. a) !he report uses the phrasemass traumatization* to describe
the e+perience of peop'e in Sierra
Leone. ,+p'ain why.
b) "o you thin- it has been and wi''
continue to be difficu't for the
citizens of Sierra Leone to recover
from the civi' war? Why?
/. &ccording to research what do
near'y a'' victims of war
e+perience? ,+p'ain why you thin-
this ta-es p'ace.
0. &ccording to the report what
percentage of peop'e suffered from
traumatic stress and !S"? "oes
this surprise you?
. "o you be'ieve that 2o'ding3s
character 4a'ph as we'' as other
boys in the nove' wou'd have
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suffered from traumatic stress or
!S"? Why or why not?