Featured Issue: Refugee Mental Health
Interview with Dr. Paul Bolton
During a series of interviews with forcibly displaced people, and in discussions with other like-minded NGOs, Their Story is Out Story (TSOS) recognized significant gaps in designing and providing trauma-informed therapy for individuals who have experienced displacement. These gaps were further reinforced by legislation and policies that did not appropriately address the mental health needs of resettled populations. To address these gaps, in 2021 and 2022 TSOS interviewed four mental healthcare professionals who each work in a different field of mental healthcare, and as such provided a broad picture of the challenges, opportunities, and lessons learned.
The following interview with Dr. Paul Bolton focuses on the global picture of how cultural barriers and opportunities help refugees heal and integrate, and what efforts have been made to design more meaningful therapy, and train more culturally and experience-wise trauma-informed counselors.
Dr. Paul Bolton
Dr. Bolton has over 20 years of experience in Mental Health and Psychosocial Support (MHPSS) working with international and local NGOs and governments. He has led program development and research in Europe, Southeast Asia, Latin America, the Caribbean, Africa, the Middle East, and the Pacific region. His research includes qualitative and quantitative studies as mixed methods, including many randomized controlled trials exploring effectiveness and implementation practices for MHPSS interventions, qualitative studies of population-specific needs, and the development and testing of valid assessment instruments. Prior to working in mental health, Dr. Bolton led humanitarian health programs on the Thai-Khmer border during the conflict that followed the ouster of the Khmer Rouge, and in Bosnia during the conflict following the break-up of Yugoslavia.
Dr. Bolton received his medical degree from the University of New South Wales, Australia. He received masters’ degrees in public health and science from Johns Hopkins University, where he continues to hold a faculty appointment as Senior Scientist in the Departments of Mental Health and International Health at the Bloomberg School of Public Health.
Tell us about who you are, how you started your work in mental health, and why you do it. What benefits do you see from it? What drives you to continue?
My original training is as a physician. I was trained in Australia, practiced there for a number of years, and then I left. I ended up in Bangkok, Thailand, and received training in tropical diseases. And then I worked on the border between Thailand and Cambodia. I worked for a Thai NGO working under the auspices of the United Nations, running a medical program. I was based in a Khmer Rouge camp on the border. This was after the Vietnamese threw them out—going into Cambodia, fighting, and coming back, and then occasionally the Vietnamese would shell the camp that we were working in. I saw a lot of malaria and tuberculosis and war injuries, and what were clearly mental health issues amongst the soldiers and the families.
I worked with other physicians, other health workers, and they didn’t seem to either see or be concerned about mental health issues like I was. I think I may have been more sensitive to it than they were due to personal interaction with depression in my family. This was in the late 1980s, early 90s. I observed that we were treating all the other aspects of their wellbeing, except mental health. That stuck with me but I couldn’t do much about it at the time.
After that job, I took on a few other international positions before ending up in Bosnia, where I led a program training local workers as medics. We started to see an interest in the mental health effects of the war among local people and the international NGOs. That was the first time I ever saw the level of interest in mental health.
The other thing that happened in the 1990s was that the first edition of The Global Burden of Disease came out. It’s a key document which attempts to list and prioritize the health issues affecting the world. What was surprising for me and other people was that mental illness, and particularly depression, turned out to be one of the major causes of disability. No one had ever really thought about that before. I know I hadn’t. I thought it was important, but I never realized it was that important.
The Global Burden of Disease document, and my prior experiences, caused me to change my focus from general medicine and tropical disease to mental health, around 1998. And I’ve been working on that ever since. The most important question I wanted to help answer was, what are the commonalities in mental health issues across populations, different cultures, and different experiences?
I’ve now worked in every region of the world on mental health issues. Most of my colleagues tend to focus on one area, for good reason: it’s a lot easier to get established in one area. With the combination of people working in one area and those working across areas, together we can figure out what the commonalities are in terms of diagnosis, treatment, management, and training.
What sort of commonalities have you seen? Not only culturally, but also gender-wise? What, if any, are the differences in how you would treat mental health issues of displaced persons as opposed to other traumas? Are there similarities?
When I first joined this field, one of the questions that we had was whether they really apply in other cultures.
Most diagnosis methods for mental health conditions—depression, anxiety, post-traumatic stress, substance abuse—were developed in the West. Do people in other cultures get these same disorders, or do they not? Do they manifest themselves in similar ways, and can they be diagnosed on the same criteria?
The answer is really clear now that yes, most disorders do occur across every culture and population that we know.
They look a little different depending on where you’re working. And some features that might be more important in the United States are less important in other places, and vice versa. But the basic structure of how these diseases occur and manifest is pretty much the same. How they are understood and what people think are the causes of them also vary across cultures, but about half the disorders are usually pretty much the same.
Therefore, we found the treatments that we have developed in the West also work, as long as you make a good effort to adapt them to the local situation—to adapt them in ways that make sense to people. If you make that effort and you apply it to people in a way that they understand and they can accept, then they will progress. If you just come in with your American way of thinking about it and doing it, they don’t want it.
We saw this right after the tsunami—the Christmas Boxing Day tsunami. People were affected throughout Asia, India, and Southeast Asia. Western therapists came in but they could not provide the best therapy, because they didn’t understand the situation. They didn’t understand the culture. And the local people just didn’t accept or understand what they were trying to do. They were just too different.
So, one of the points I’m getting at is that you really do need to have these programs and interventions provided by people from the same culture, and preferably similar experience, to the person receiving them. There are a couple reasons for this. One is that if the person receiving the program senses that the person delivering it is like them, and has some understanding of the situation, they’re more likely to accept them and to trust them and to know what it is they’re talking about. The other is that both sides need to be able to negotiate what’s going on. This happens a lot in mental health treatment: you don’t just sit there as the therapist and deliver. You listen to what the person is saying and then respond. You tailor what you’re saying to what the person has said to you. And that’s important.
So, in the programs that we do, we introduced a program of psychotherapy study for depression. Say it’s a place that we’ve never been. We’ve not been in that culture before. We would take one of our existing manuals, and we would identify people in that country and particularly in those communities that we wanted to train. And we would identify people in the country who can translate the manuals, translate the training instruments, etc.
The first thing that happens is you deliver that manual to the translators, and then you go back and forth about how we are going to translate it. Because the translators will tell you, “That phrase doesn’t mean anything because it’s too technical. It’s too jargon. That’s not an example we would ever use.” So in that way, you end up with a translated version of the manual, which you then share with the trainees, and then you go through exactly the same process. We say the same thing to the people we train: Okay, how does this look to you? Does this make sense? Do you think people can accept it? And again, you go back and forth until you have a manual that they like. And then you go and do the training, which pre- COVID usually involved trainers going out to places and training local people. And during the training, it’s the same thing: “So, here’s what we’re going to talk about today. This is how we think about this. Do you think this makes sense?” And again, back and forth until we have an approach that makes sense for that culture and that area.
How many of these trainings has your team conducted (early 2021)?
It’s probably about fifteen. And again, it’s in each region of the world. We’ve done it in Northern Africa, Southern Africa, Eastern Europe, and the former Soviet Union. We’ve done it in South America, Central America, North America. We’ve done it in the Pacific, Southeast Asia, and India.
How long is the training? Are there multiple modules, and over what course of time are they administered? Is it something that takes a long time and a lot of money?
The only way that we have figured out how to really effectively train people in skills is through an apprenticeship. Everyone is trained as an apprentice.
What typically happens is once you have translated manuals, you get someone who can really effectively treat depression, anxiety, post-traumatic stress, substance abuse. Then we give them about two weeks of training. After that, they treat a pilot case under supervision—just one or two people. And then after that, they start to treat more people. Every week they report to a local supervisor, and that supervisor reports to the trainer, usually by phone or internet every week.
That goes on for six to nine months until we’re satisfied that the person is competent and can be left to do this on their own in their own way. After that, supervision becomes ad hoc: it’s in-person meetings. So, the entire training process takes about six to nine months, depending on how many cases they see and their own natural abilities. Two weeks of intensive training, a pilot case that they can get through in about one to two months, and then the whole process is followed by weekly supervision.
The expense is mainly a person’s time, because this is psychotherapy. We don’t use drugs. We don’t use equipment. What we actually do use is a computer and an internet connection or phone line, and then the time of the trainer.
We instituted this train the trainers approach, for example, in Burma, and now we have trainers there. They don’t need the Americans anymore. They can train their own people and they can supervise them. They have a similar group in Ukraine. We have another group in Iraq, and we have another group in Zambia. All over the world, we’re trying to build these local cadres of trainers who can work and function without us.
Here, in the United States, we try to train those in similar time zones because of supervision issues. So you would probably still use Americans, at least for the training of supervisors or trainers. I guess the issue again with this keeps coming back to licensing.
Tell us a bit more about the challenges in administering the training.
In countries where there are few or no mental health professionals we will look for ordinary people who have no mental health background, who have at least a middle school education and show some affinity for this type of work. They like counseling with other people. They’re friendly, they’re engaging. Those are actually more the qualities we’re looking for.
One of the countries that we work with is Ukraine. We actually had more difficulty training the clinical psychologists there than we had in training the experienced people I just described, because the clinical psychologists were trained in different methods. But people who only have a general feel for this usually are a blank page, and they actually do really well because they don’t have an academic background or mental health background that is different from the program being introduced.
In some countries, we do face the challenge whether lay trainees can get licensed without a traditional training and certification in mental health. Does the law allow them to do this? In North America, colleagues were able to do a program on a native reservation out west because they have their own government and were recently approved to do a program in Washington state. But the challenge is that in Western societies, we face the obstacles of being limited to only training clinical psychologists, which was the case in Washington state. However, while well intentioned, traditionally trained clinician psychologists are oftentimes removed from the refugee experience and have a hard time establishing the rapport and understanding needed to provide the full benefit of the training and mental health treatment.
If we had a state that piloted this program could it create a domino effect for other states wanting to take it on?
Yes and no. Just proving that a program is effective and helpful is not enough to create a law-related change. It would require the people who control the licensing and professional clinical psychologists and social workers to come on board with this and support it, which means trying to figure out under what circumstances they would feel comfortable with it.
I think you have an excellent argument, though, for refugees. You can make the argument, “Look, it really needs to be people who understand the experience of these folks.” Any clinical psychologist would understand that.
What gender issues do you see come up in mental health? Are men or women more likely to seek therapy? On the other hand, do you see gender-focused groups that seem more interested in the training and become counselors? What gender-cultural challenges need to be considered when training an individual?
I’ve generally found that, across the board and across different regions, women are okay with having a male counselor, as long as it doesn’t violate cultural norms. Men, however, are not as accepting of having a female counselor, unless it’s someone quite a bit older than them. Because then it seems to tap into the more elderly, motherly kind of thing. But if you had two women, as you said, in their twenties, and they wanted to be counselors, I don’t think they would get many men going to them. You really need to have a group of male counselors for those males that only want to deal with another man.
In terms of issues across the board, men are much more likely to reach for alcohol and substances than women as a coping mechanism for what they’re going through. They’re also much more likely to be violent, also as a coping mechanism. Domestic violence is mostly a way in which men cope with the stress and problems that they have on their own where they haven’t really learned to deal with it in a better way. Colleagues who work with domestic violence don’t report that men who beat their wives enjoy it. The problem, more often that not, is that they have a limited range of dealing with their problems, a limited scope. Violence may make them temporarily feel a little relieved or less stressed, but then they regret it.
Very often in families, including refugee families, the biggest mental health issue that a woman or a child has is actually the mental health issues of men in that family. Those issues need to be dealt with for the family and for the individual, because men have power. They have both authority based on culture, in most cultures, and they have physical power. So, we very often have to deal with the man’s issue, as well as with the individual issues of the wife and the children.
Men seem to express depression differently from women. Most of the depression instruments that we have, the ways of diagnosing depression, are female. With depression, women are much more likely to talk about sadness and crying. Men are more likely to talk about aggression, which is actually not part of the typical depression assessment. So, I think that for men, depression is frequent, but it’s under-diagnosed and makes it look like women get it more often. Men are less likely to talk about their problems than women are. They are less likely to consider talk therapy to be a real worthwhile activity. And so, in that sense, you need even more to have male counselors to try to do whatever you can to get them to accept it.
Does every refugee need trauma therapy?
Only some people need full trauma therapy. And they need it at different times. What every refugee and displaced person needs is access to assessment, and not just at one point in time.
It’s so difficult to predict who’s going to have real severe trauma problems and who isn’t. When I worked as a doc in the refugee camp in the Gulf of Thailand, we had a lot of people from Vietnam who ended up there. Some women who had just been raped, and then when we saw them, their main emotions were relief that they had gotten out of that situation. Yet other women who’ve been through a similar situation were just devastated. You can’t predict how traumatic events will affect a particular person. But then I always wondered whether in six months, they might start to develop issues when they’ve gotten over the fact that they’ve been rescued. They might start to think about and realize what they went through.
So, what I would say is that everyone needs assessment, and access to assessment at regular intervals. And for those whose assessments show they need more help, they need access to treatment. The assessment is important, because you don’t have to have the capacity to treat every single person. Not everyone is going to have to work on full-time issues, and they’re not all going to happen at the same time. You don’t necessarily need a full army of people. You can get by with less capacity than that. Usually, we operate on the figure that we’ve seen across cultures: between ten and twenty percent of any group of people at any one time probably need additional assistance in the form of treatment.
In the assessment, you assess the presence of symptoms and problems with functioning. You don’t ask the person what happened. The reason why therapy can be harmful is basically two things. One, requiring a person to identify having an experience that they don’t want other people to know about. And two: asking them to recall events when they’re not ready to do so. Those are really the two dangerous parts of therapy. For example, I was working with an organization in Mexico, and they were lawyers. They had a very good goal of helping torture survivors advocate for themselves before the courts. But they required that everyone that came through the door told their story. And it just wasn’t a good idea, let me put it that way. When people are ready to tell their story and then motivated, that’s great. But if they’re not ready and they’re being encouraged to do so, that’s not good.
Refugees brush shoulders with people that are NGO workers, volunteers, and others in welcoming centers. These people are like those you talk about in Mexico—their hearts are in the right place, but they are not trained to actually understand the trauma that refugees have been through. Do you have any recommendations for how to train volunteers on addressing and recognizing mental health issues and symptoms? Would such training be something you recommend to any NGO that deals with refugees?
I think there are three types of training we can give people, depending on their role.
First, there is what we call trauma-informed programming. Different people have different definitions, but I can tell you about what WHO calls trauma-informed programming. It’s programming that takes into account the fact that the person has been through trauma, but doesn’t deal with that trauma. You don’t ask the person to identify having certain experiences and don’t ask them about the events. If they want to talk to you about the events in a limited way that seems to make them feel better, that’s fine. If they want to talk to you about the events in a bigger way, then you need to refer them to somebody who has more experience.
The second type of training is training people to deal with trauma itself. So that could be the kind of person that those folks get referred to. The point being, they’re ready to talk, they want to talk, and they want to do it in a way that is not going to make things worse. So they are referred to someone who is trained to deal with trauma, as opposed to the first person, who’s only trained to do no harm. The person who is trained to deal with trauma would be the person who’s trained in active listening, who understands how to respond to what the person’s telling them, without probing in ways that can be damaging.
The third type of program is someone who’s trained to deal with all issues. And the reason for that is that we rarely find someone who has just trauma or just depression, or just anxiety, or just substance abuse. It’s not common. It’s more common that people have depression and anxiety, or depression and anxiety and post-traumatic stress and substance abuse. Because comorbidity like that is frequent, treatment of those folks is actually a lot better if you deal with all the issues, rather than just the trauma. So the training that we tend to give people, and which we recommend, is a training in which you are actually equipped to deal with whatever constellation of problems the person comes in with, and not just the trauma. We find that even when people have been through really horrific events, if their current situation is challenging, then their day-to-day mental health symptoms are more often derived from that difficult current situation than from the trauma itself. And so they need to deal with it.
When you’re a refugee, the biggest thing that you deal with on a day-to-day basis is not trauma. It’s loss. The loss of your culture, loss of your old supporting group, loss of your family if you had to leave some of them behind, loss of the ability to go out and socialize with people in a way that you understand and that you can cope with. It’s all loss when you’re a refugee, and in the early days of transfer, you don’t see the positives.
Eventually you’re going to come up with new coping mechanisms and new social structures that are going to help you fill the gap. But until you have those, it’s all just loss. Which is really tough.
How can we apply these principles to our own interviewing and storytelling techniques at TSOS?
The way we tend to interview is using open-ended, quantitative methods. They’re the equivalent of putting the person in a situation where they’re open to talk about whatever they want to talk about. Each question is not an insistence, but rather an invitation to talk. The person is free to take the invitation or not.
It’s the difference between an open-ended question and a questionnaire. In open-ended questioning, you invite a person to talk. In a questionnaire, you ask them something very specific that they have to respond to. We would only ever use the latter for symptoms and function. If we are actually interested in the events for some reason, we use the former—qualitative interviewing, because it’s invitational. And we make that clear. The person can just talk about the things that they feel like they want to talk about.
The other thing you might consider is that this kind of interviewing, if you do a lot of it, can actually affect your own mental health. You need to be careful about that, too. I’ve had situations where we’ve had to retire interviewers because it was getting to them. You have to be careful about your own mental health.