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Heartache and Healing

Psychology Professor Ken Miller works with refugees around the globe, from Guatemala to Afghanistan to Sri Lanka. Amid the suffering, he finds signs of hope.

Associate Professor of Psychology Ken Miller spent part of his summer in a Sri Lankan village where residents are so fearful of being attacked after sundown that they head into the jungle or to other villages every single night for sleep.

On the night of September 18, 1999, members of the Tamil Tigers, many of them young women, entered the Sinhalese village of Gonagala and slaughtered 44 people  in their homes, including several children. Seven years later, the memories remain powerful, and with renewed fighting in the island nation's northern and eastern regions, so do the fears that it could happen again.

Come morning, however, the villagers of Gonagala filter back home and start their work in shops and rice paddies; their children walk to school in bright uniforms discussing their plans to become teachers, farmers, or doctors someday. "There is a resilience to the human spirit that's just extraordinary,'' says Miller. "There's this insistence (that) ' We will not stop living our lives.'"

In 15 years working with victims of organized violence, Miller has been troubled by the depth and magnitude of human suffering -- and buoyed by the courage and resilience of the people enduring it. From Guatemala to Bosnia to Afghanistan and beyond, his academic work has come to revolve around the theme that Western mental health professionals can't assume they know what war-affected people in different cultures need in order to heal and rebuild their lives. Instead, these professionals need to develop methods of intervention and measures of well being that make sense within each culture. To accomplish this, Miller says, they need to shift gears, leave behind assumptions and carefully listen to the concerns of local communities.

Part of his work in Sri Lanka, conducted with Dr. Gaithri Fernando of Cal State L.A., involved assessing the psychosocial needs of 700 Sri Lankan teens from the three main ethnic groups: Sinhalese, Tamils and Muslims. Using a mixture of methods ranging from small focus groups and a children's photography project to a large-scale survey, Miller is hoping the data collected (and still being processed) will allow the researchers to create culturally-appropriate needs assessment tools and will aid the development of useful interventions geared toward children. Miller and Fernando also spent considerable time in the village of Gonagala, where the 1999 massacre took place, filming a documentary about the experience of the community and its remarkable resilience. They are currently looking for funding to complete the production of the film.

The Sri Lanka research follows his recent work in Afghanistan, where, with anthropologist Patricia Omidian, Miller trained a team of Afghans to conduct interviews with community members, asking them to identify indicators of distress and wellbeing by describing people they knew who had suffered because of the war and who were either still suffering or were now doing well. This led to the development of the 23-item Afghan Symptom Checklist, which was administered to 320 people throughout the capital.

Through this method, Miller discovered that Afghans were "much more likely to describe their war-related distress in terms of jigar khun, (dysphoria associated with experiences of loss and other hardships), asabi (a combination of nervousness and anger) and fisha-e-bala (feeling highly pressured or stressed)," according to a soon-to-be-published research paper Miller co-authored. The development of this checklist is discussed in two forthcoming papers: The Afghan Symptom Checklist: A Culturally Grounded Approach to Mental Health Assessment in a Conflict Zone" and "Beyond Trauma-focused Psychiatric Epidemiology: Bridging Research and Practice with War-affected Populations." Both papers will appear in the October 2006 issue of the American Journal of Orthopsychiatry.

In recent years, Westerners working in war-and-disaster-torn nations have tended to focus on measuring and addressing symptoms of Post Traumatic Stress Disorder, which was originally noted in Vietnam War veterans and received formal recognition as a psychiatric disorder in 1980. Symptoms run from nightmares to intrusive images to sleep troubles.

The big question, says Miller, is whether PTSD is a universal phenomenon. Certainly, some of the symptoms may be experienced in trauma victims the world over. But there may be other, more culturally specific ways of experiencing and expressing distress, says Miller.

"You want to be able to talk to people about distress in ways that make sense it them,'' says Miller, co-editor of the 2004 book The Mental Health of Refugees: Ecological Approaches to Healing and Adaptation. "If you have the belief that you already know how suffering is expressed and what people's concerns are, why would you bother going in asking people what their concerns are and how they experience distress?"

Miller notes that PTSD draws on the Western psychological notions that 1) people expect the world to be just and 2) traumatic events shatter that view. But that "just world hypothesis" may not hold be relevant in nations where people live in conditions of continuous violence and profound inequality, says the professor.

In many cases, it turns out that refugees and other survivors of violence and disaster tell professionals they need practical help to aid their well-being. In Sri Lanka, for example, children living in refugee camps have some very fundamental needs such as temporary housing that snakes can't get into, access to water, privacy and protection from sexual abuse. In Afghanistan, people cite poverty, social isolation and separation from family, as well as safety issues.

The specific problems vary, but this emphasis on concrete measures is something Miller has encountered over and over since he started in this field working with Guatemalan refugees in 1991. There he quickly learned "you had to deal with what was going on in people’s day-to-day lives,” he says.

This creates a new role for the helpers from the West. Miller sees their task as one of helping to strengthen social support networks weakened by disaster or violence. It’s a matter of helping local organizations develop interventions that work best in their setting.

The good news, Miller says, is that research shows community-level volunteers can be just as effective as highly-trained professionals at helping people recover from impact of organized violence and displacement. What strikes him is how communities find ways to survive and bounce back, defying the tragic images that fill the news. “It’s so empowering to see communities regain their hope, to seeing healing happen, to see social networks return,” Miller says.

This evidence of human resilience encourages Miller to keep at work that can bring him into contact with horrifying realities. “It’s something that gives my life meaning,” he says. “It’s a tiny drop in the ocean – but it’s a drop.”