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Finding Out What Doesn't Work

By Jackie Powder

For the AMHR researchers, determining what doesn’t work in certain settings is as important as putting in place effective mental health interventions. “You shouldn’t be out there promoting change and providing services for people if you don’t know that you’re doing more good than harm,” says Paul Bolton.

Case in point: AMHR’s collaboration with an international NGO to assess the problems of urban street children.

“I guess, being naïve, one of the things I originally thought was that most street children would be orphaned,” Bolton says. “It turned out that most children are not at all orphans. Many either have contact with families or know exactly where to find them. A significant number of kids who choose not to have contact with their families do so because the situation on the street is better than the situation at home.”

 Some of the children had been kicked out. Some left voluntarily.

But for many the street was a better option than what they had left behind at home. Based on these findings, AMHR and the NGO partner concluded that the NGO’s focus on returning the street kids to their homes might not be the ideal solution.

Thousands of miles away, in Indonesia, AMHR researchers were called upon to evaluate a program already in place among people living with depression and anxiety in Aceh. The region had been caught for more than two decades—until 2005—in a violent conflict between the Indonesian government and GAM (Free Aceh Movement), an army of resistance fighters. Indonesian troops looking for rebel fighters hiding in Aceh jungles burned down entire villages, and beat and tortured residents. “The military would round up 10 people and beat them up in the village squares; there was raping of women,” says Bhava Poudyal, a program manager with AMHR’s partner in Indonesia, International Catholic Migration Commission (ICMC).

In Aceh, Poudyal oversees an intervention in which participants—including torture survivors—meet in groups under the guidance of a trained moderator to talk about their problems and explore coping mechanisms.

To evaluate the effectiveness of the intervention, Bass and ICMC developed a questionnaire aimed at capturing an accurate picture of mental health problems in the area. The questionnaire—adapted from a Western mental health measurement—uses a scoring system to determine an individual’s level of mental distress. The AMHR researchers modified it to reflect the culture of the target population. For example, “they talked about thinking too much, and we added that because it wasn’t on the original questionnaire,” Bass says. “The population told us about crying and feeling sad, so we used their terms for these problems in our measure."

AMHR then set up a trial to compare the effectiveness of Poudyal’s existing intervention of group counseling sessions with a control group.  The results?  “At this time, in this place, [the intervention] didn’t reduce symptoms of depression and anxiety,” Bass says.  However, the findings did reveal that intervention participants on average exhibited significantly improved functioning and reported significantly higher use of positive coping strategies compared with controls. The data also suggested improvement in relationships, although this was not part of the original assessment.  The widespread poverty in the area could be an underlying cause of the villagers’ distress, which, unaddressed, could be a reason that we were not able to see improvement in the symptoms.  Bass and ICMC staff discussed the findings with the counselors, and together came to a decision to pilot a new approach that pairs counseling with a component intended to improve clients’ economic security. 

“In this situation,” says Bass, “We found out something did not address the mental health symptoms as intended, so let’s strategize and improve the intervention, pilot those changes and actually evaluate the newly adapted intervention.  It’s public health research being done to improve practice, as opposed to saying, ‘Let’s keep doing what we’re doing.'"