assessing trauma in sierra leone

7/24/2019 Assessing Trauma in Sierra Leone

1/7

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 +,


2/7

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


3/7

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


4/7

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


5/7

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.


6/7

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


7/7

suffered from traumatic stress or

!S"? Why or why not?

assessing trauma in sierra leone

Documents