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Psychology International ◦ DECEMBER 2014

Promoting an International Perspective in American Psychology By Bonnie Kaul Nastasi, PhD & Sissy

Hatzichristou, 2014 , PhD, Co‐Chairs, CIRP (Commi ee on Interna onal Rela ons in Psychology)

CONTENTS

COVER: Promoting an International Perspective in American Psychology

Strong Voices from the Caribbean…………….…….…….3

Psychology in the Democratic Republic of the Congo: Its Struggles for Birth and Growth…………………....….…..5

Global Networking Forum Series with The Chicago School of Professional Psychology………………..…….12

2015 APA International Awards…………………………..12

Psychology in Cuba……………………………..13

Selected Review from PsycCRITIQUES ......................15

Recently Published .................................18

UN MATTERS: A First Person Account of the Refugee Experience: Identifying Psychosocial Stressors and Formulating Psychological Responses……………..…….….7

ANNOUNCEMENTS ................19

Volume 25, Number 4, December 2014

For an online version, visit: www.apa.org/international/pi

NEWS AND UPDATES FROM THE AMERICAN PSYCHOLOGICAL ASSOCIATION OFFICE OF INTERNATIONAL AFFAIRS | DEC. 2014

APA Office of International Affairs

PSYCHOLOGY INTERNATIONAL

Since 2013, the Commi ee on Interna onal Rela ons in Psychology (CIRP) has renewed its commitment to the APA’s mission to excel as a principal leader and global partner promo ng psychological knowledge and methods to facilitate the resolu on of personal, societal and global challenges in diverse, mul cultural and interna onal contexts. Consistent with APA’s aspira ons, CIRP iden fied two major priori es:

1. Promo ng an interna onal perspec ve within APA 2. Promo ng an interna onal perspec ve in graduate programming in psychology

Our work began with considera on of the varia on in terminology and perspec ves about what cons tutes an interna onal perspec ve. One of CIRP’s first steps in 2014 was to establish a subcommi ee that would address the ques on of, “What are interna onal competencies for psychologists?” The subcommi ee is in the process of iden fying cri cal competencies related to psychology research, prac ce, teaching, service, and policy. It is expected that the outcomes of this work will influence how we address our major priori es. An ini al report from the subcommi ee will be made at APA’s 2015 Na onal Mul cultural Conference and Summit, to be held in Atlanta in January. Given the 2015 theme, “Psychology Without Borders: Reaching Within, Reaching Out,” the summit provides an opportune context for the presenta on and discussion of what cons tutes ‘interna onal’ competencies to guide our work as we ‘reach out’, and how those are dis nct from ‘mul cultural’ competencies applicable as we ‘reach within’.

In addi on to the interna onal competencies ini a ve, CIRP has also undertaken the development of two resolu ons: (a) Resolu on on Promo ng Global and Diverse Perspec ves in US Psychology; and (b) Resolu on on Gender Awareness in Interna onal Psychology.

(Con nued on page 2)

2 www.apa.org/international/pi

Psychology International ◦ MARCH 2014

These would replace the 2004 Resolu on on Culture and Gender Awareness in Interna onal Psychology, and serve to highlight issues related to promo ng a global perspec ve in general as well as gender awareness from an interna onal perspec ve. The work on these resolu ons is ongoing. The work on interna onal competencies and resolu ons related to promo ng a global perspec ve and addressing issues of gender in interna onal psychology reflect our commitment to facilita ng an interna onal perspec ve within APA. In addi on to these efforts, CIRP con nues to work closely with APA’s UN team based in New York City, led by Janet Sigal, PhD, as the APA representa ons to the UN work on issues such as child rights, global violence, the status of women and girls, and aging. In addi on to the current ini a ves, CIRP recently completed two brochures to provide informa on relevant to psychologists’ work in the global world: (a) Interna onal Research Brochure; (b) Translated Measurement Instruments Brochure. As we enter 2015, CIRP will con nue in its efforts to pose and address cri cal ques ons relevant to extending the focus of APA and American Psychologists to encompass both global and local perspec ves. We look forward to working in partnership with other sectors of APA to ensure that individually and collec vely we can engage effec vely in mee ng the global challenges of the 21st century. Members of CIRP 2015 include: Rehman Abdulrehman, PhD, CPsych, Chair Silvia S. Cane o, PhD Melissa Morgan Consoli, PhD Chryse Hatzichristou, PhD Arpana G. Inman, PhD Lori Foster Thompson, PhD Gonzalo Bacigalupe, EdD, MPH Amanda Clinton, PhD

Danny Wedding, PhD Ψ

Eight Annual Psychology Day at the United Nations

Reducing Health Inequalities Within and Among Countries: Psychological Contributions to the UN’s Post-2015 Global Agenda.

THURSDAY, 30 APRIL 2015,

3-6PM AT THE UNITED NATIONS HEADQUARTERS

NEW YORK CITY, NY

For more information and to register, visit: http://www.unpsychologyday.org.

14th European Congress of Psychology July 7-10, 2015

Milan, Italy

Web: http://www.ecp2015.it/it/

Theme: Linking Technology and Psychology:

Feeding the Mind, Energy for Life.

www.apa.org/international/pi 3


Strong Voices from the Caribbean

By Merry Bullock, Senior Director, APA Office of Interna onal Affairs (OIA)

In November, psychologists from 19 Caribbean countries and territories and from 9 other countries met at a vibrant

conference with the theme “Caribbean Psychology: Unmaking the Past and Claiming Our Future.” Held under the auspices of the Caribbean Alliance of Na onal Psychological Associa ons (CANPA), and hosted by the Suriname Associa on of Psychologists and Special Educators (SVPO), the 2nd Caribbean Regional Conference of Psychology (CRCP2014) con nued the goals of the first conference (CRCP2011) to bring together psychologists from across the Caribbean region to develop a psychology that addresses the needs and reali es of the region.

CRCP2014 was organized to encourage shared experience, dialogue and exchange. Each day included all‐conference plenary sessions in which two speakers spoke to each of the Conference’s 5 themes, as well as other sessions – symposia, round tables, panels, and posters – that promoted discussion a range of topics‐ there were 130 presenta ons in all.

A er a full day of pre‐conference workshops, and a warm welcoming ceremony, the conference began with two keynote talks. David Commissiong spoke on the history, context, and role of the repara ons movement to “unify, heal and transform” the Caribbean in his talk, “Repara ons: A Caribbean constructed Instrument for Survival and Transforma on”. Marcia Sutherland spoke to the need to develop a pan‐Caribbean psychology to address mental health, psychosocial wellbeing, and development at personal, community, na onal and regional levels in her talk “Pan Caribbean Psychology: A Tool for Caribbean Regional Development”. Other plenary talks addressed Caribbean iden ty and iden ty development, public health approaches to well‐being, development of science‐based policy in the Caribbean, the status of clinical psychology, indigeniza on processes, and challenges to developing a psychology that is a uned to and relevant in the Caribbean context (the complete program can be accessed here).

The discussion in panels, symposia, roundtables and poster sessions was lively. Common themes included the importance of developing methodologies, tools, and models that are Caribbean based and that respect the varied cultures, languages and histories of the region; the need for na onally relevant research and educa on materials; surveys or in‐depth studies of a tudes, knowledge and behavior relevant to health and mental health; reports of clinical prac ces; reports addressing the legacy of colonializa on and slavery; and presenta ons on resiliency, tradi onal healing, family issues, schooling, and policy.

In addi on to presenta ons, conference a endees came together for a welcoming recep on in a pavilion overlooking the Suriname River, for a film “Sombra di Koló or Shadow of Color (see h ps://www.youtube.com/watch?




v=i3DSdZhOISQ) and a ended “Cultural Night” where they watched and par cipated with dancers and drummers represen ng the many cultures of Suriname. Suriname, the host country to the conference, is a small na on with one of the most ethnically and culturally diverse popula ons in the world, stemming from a history of colonializa on (Bri sh, Dutch), slavery (West and Central Africa), contract laborers (China, India, and Indonesia) and local first peoples (Amerindians). Today 27% of the popula on is of East Indian origin, 21.7% Maroon (descendants of escaped and former slaves who established independent communi es), 15.7% Creole (primarily African‐European), 14% of Indonesian origin, 10% of Chinese origin, about 3.7% indigenous americans, and small percentages of people from other origins, including Europe (primarily the Netherlands and Portugal), Middle East (Lebanon), descendants of Sephardic and Ashkenazi Jews, and Brazilians. Suriname, which independent since 1975, is presently the smallest independent na on in the americas, and the only one where Dutch is the primary language spoken.

The psychological associa on of Suriname, SVPO, is one of the 13 current organiza onal members of CANPA, the Caribbean Alliance of Na onal Psychological Associa ons. Although CANPA was officially founded only in 2013, its beginnings were confirmed at the conclusion of the 2011 CRCP when the delegates declared in the “Nassau Statement” an intent to form an organiza on that would foster the development of psychology organiza ons, educa on, training and applica on in the Caribbean, to promote mental health and psychosocial wellbeing of Caribbean peoples. The other organiza onal members are na onal psychology associa ons in the Bahamas, Barbados, Cuba, the Dominican Republic, Grenada, Guyana, Hai , Jamaica, Mar nique, Puerto Rico, Trinidad & Tobago, and the U.S. Virgin Islands.

As a regional organiza on, CANPA’s purview is suppor ng psychology throughout the Caribbean. Addressing the diversity and celebra ng the rich variety of cultures and languages in the region is a challenge that CANPA embraces – its conferences will rotate among CANPA member countries to embrace the languages of the region (Creole, Dutch, English, French, Spanish). During CRCP2014, CANPA held its first general assembly and established an execu ve commi ee, officers, and standing commi ees (see www.canpanet.org). The next CRCP, planned for 2016, will be in Hai – see www.crcp2016.org.

Please send your comments to [email protected], subject header ”Internationalization.”Ψ

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One encounter with the mother of a nine‐year old in my office as a priest in Kinshasa (Capital city) offers a panoramic view of psychology in the Democra c Republic of Congo (DRC). One early morning, a late‐40s woman approached me and shared the heartbreaking story of her family. With tears, the woman held out her nine‐year old daughter and asked me to “exorcize” her because she was “possessed” by bad spirits. Touched by the woman’s story, I asked her for more details about the origin of the bad spirits and how her daughter became possessed. The woman told me that everything started when some of the soldiers in the Eastern part of the DRC entered their house and told her husband to rape her and her two small daughters. When the husband refused, the soldiers killed him and raped the woman in front her children and then raped her two daughters. A er these rapes, the woman, s ll weeping, told me that her daughter started “jumping” at night and was afraid of men and did not want to be in school. The woman never understood why her daughter was exhibi ng these behaviors, exclaiming: “She needs to be exorcized from all these bad spirits. Please pray for her.” Bewildered by the woman’s story and ignorant of what was going on, I decided to refer the woman and her daughter to a psychiatrist and to also offer them my prayers. Over the course of many conversa ons, the mother and I began to understand that her daughter’s dreams and flashbacks, withdrawal from social life, impaired concentra on and sleep disturbances were all related to her history of sexual abuse and having witnessed horrific family trauma.

In the DRC, formerly known as “Zaire” and situated in the central part of Africa, there is s gma a ached to people and the lager family of these people suffering from behavioral health problems. The cause of mental disorders is o en sought in witchcra or “black magic.” The shame of having a mental disorder extends to the family because each person is an integral part of a larger familial and social fabric. It is never just an individual who suffers from depression or schizophrenia and who is being treated for mental disorder; it is also the family, clan, and tribe that suffers and must be treated. The people suffering from mental disorder and other family or community are at risk of being accused of sorcerers or witches. Consequently, the first consulta on is not with a psychologist or physician, but with a tradi onal healer or priest (a Nganga‐Nzambe, or “Healer of God” in the Lingala language). Chris an or Muslim Congolese likewise seek healing for their inner problems from their pastors or imams rather than from a psychologist. It is very rare that a Congolese visits a psychologist or psychiatrist for behavioral health concerns (Schuster, 2013).

Mental Health Facili es Psychology in the Congo, the second largest country in Africa in terms of area and 11th in the world, serves the ny minority of Congolese with higher educa on rather than for the vast majority of its 75 million. There are only 6 mental health hospitals in the country with 500 beds, which means there are 0.737 beds per every 100,000 people. Kinshasa, the capital city, has 1 mental health outpa ent facility, the Centre Neuro‐Psycho Psychiatrique de Kinshasa (CNPP). There are no day treatment facili es, no dedicated psychiatric beds in medical‐surgical hospitals, and no beds in community residen al facili es (Mental Health Atlas, 2011). The Na onal Director of DRC Mental Health, Dr. Muteba, has unscored the lack of trained mental health personnel in the country (Schuster, 2013). There are 34 neuropsychiatrists (0.066 per 100,000 people), 0.044/100,000 psychiatrists, and 0.236 /100,000 psychiatric nurses. There are only eleven doctoral level clinical psychologists (0.015/100,000), 0.018/100,000 social workers, and 0.001/100/000 occupa onal therapists. Almost all these mental health professionals work in the capital city, with few to none in rural areas (e.g., 30 out 34 neuropsychiatrists work in Kinshasa) (Interna onal Psychiatrist, 2010; Shuster, 2013).

Psychological Departments in the Congo Psychology is not yet a well‐known and accepted discipline in many DRC universi es. Although it is taught in major universi es in Kinshasa, Lubumbashi, Kisangani, and Kananga, there are only two clinical psychology programs in the country (Kinshasa and Kisangani). Psychology programs remain more theore cal than prac cal. For example, although some students have some classes in psychological assessments, therapeu c methods, and sta s cs, they do not have laboratories, materials, or placements that provide hands‐on or experien al learning.

Psychology remains primarily a tool for understanding the different stages of human development in the training of future secondary school and primary school teachers. In DRC universi es, the study of psychology is, therefore, closely associated with the discipline of educa on. In addi on, many students do not want to enroll in psychology because job opportuni es


By Jean Ikanga

Jean Ikanga is originally from the Democratic Republic of the Congo and completing a doctorate in Clinical Psychology at the University of Detroit Mercy.

Psychology in the Democratic Republic of the Congo: Its Struggles for Birth and Growth



are scarce to non‐existent. One assistant professor at the University of Kinshasa indicated that there are less than 200 students studying psychology compared to more than 1000 students in other departments. He added that the Congolese workforce (e.g., school, industry, sport, army, and healthcare) does not have a wri en job descrip on for a psychologist. Therefore, psychology suffers from an iden ty crisis both in DRC universi es and in the larger Congolese society. This problem has led to shortage of health professionals working in the DRC mental health sector.

Western Psychology and Congolese Culture The Bantu philosopher, John S. Mbi (1995) provides this explana on of the individual within tradi onal African socie es: “The individual does not and cannot exist alone but exists corporately. He [sic] owes his existence to other people, including those of the past genera ons and his contemporaries. He [sic] is simply part of the whole. The community must therefore make, create and produce the individual; for the individual depends on the corporate group” (p.106).

Therefore, many of the psychological theore cal orienta ons (e.g., psychoanaly c, psychodynamic, humanis c and existen al, and cogni ve behavioral) in which most of the Congolese psychologists are trained deal with the client/pa ent as an “I” rather than a “We” and Congolese psychologists are s ll striving to develop a well‐researched and culturally appropriate therapeu c orienta on for the Congolese people.

The psychiatrist, Denis Bazinga, has ar culated a Congolese “We‐centered” therapeu c method, called “La Psychopalabre”. This therapeu c model is based on the Congolese tradi onal “we” model of “palabra”, which consists of uni ng all the family, tribal, and ethnic members to discuss the healing process of a member of the group who is sick. Every member of the group freely expresses her/his view about the e ology and the means for healing. This Congolese method has been used as a therapeu c approach for more than a decade with some reported success (Mangoni & Bazinga, 1987). In terms of psychological assessments, psychologists Ignace Ngufulu and Alphonse Tshimanga have translated some intelligence tests into the Congolese cultures. However, much more needs to be done to create culturally appropriate Congolese assessment and treatment approaches.

Challenges for Psychology in the Congo There are many challenges facing psychologists in the Congo. DRC psychology is burdened by a mul plicity of languages and tribal groups. The DRC has 432 tribes, 4 na onal languages (Swahili, Kikongo, Lingala, and Tshiluba), and one official language (French). Therefore, psychologists trained in the West must learn tribal languages to render linguis cally competent psychological services to many clients/pa ents. In addi on, the language ques on remains important for research because every transla on necessarily betrays the original genius of a language and culture.

Another challenge for psychology to emerge as a science in the Congo is related to illiteracy in the country. Although the literacy rate is es mated at 69% for men and 62% for women (Mental Health Atlas, 2011), few among these literate men and women have a college or university degree. Many Congolese lack a quality educa on. This situa on is related to civil wars and lack of government resources in suppor ng educa on and paying teachers. Illiteracy poses real challenges for research, psychological assessments, and many treatment approaches.

In sum, psychology in the DRC is s ll struggling for its birth and growth as a science and clinical approach to addressing the mental health needs of its people. The DRC needs culturally indigenous mental health professionals to develop therapeu c approaches that are based on the Congolese culture and constructs. The Congolese psychologists can build a posi ve image of psychology in Congolese society by collabora ng on the crea on of an associa on of Congolese psychologists. Further, psychologists around the world, par cularly other African na ons, can support the growth of psychology by consul ng on the crea on of an Africa‐centric academic curriculum tailored to its cultural reali es. APA and our colleagues interna onally can support the efforts of Congolese psychologists to create and norm psychological tests for use in Congolese society. Our colleagues throughout the world can assist in training Congolese therapists in evidence‐based prac ces to deal with trauma, rape, child soldiers, HIV/AIDS, post‐trauma c stress disorder, and other consequences of a society s ll recovering from violence and war.

References Mangoni, T.M., & Bazinga, D., Therapie par la psychopalabre: descrip on et analyse du cas d’un sujet Ngande (Bas‐Zaire) declare schizophrene, Revue Zaroise de Psychologie et de Pedagogie, 1985, Vol 4 (1), 77‐108. Mbi , S.J., (1995). African Religions and Philosophy. East African Educa on Publishers, Nairobi, 290. Royal College of Psychiatrists, Interna onal Psychiatry, 7 (2), 2010, p.42 Schuster, A., (2013).Republique Democra que du Congo: Soins psychiatriques. Rensignement de l’analyse‐pays de l’OSAR. Schweizerische Fluechtlingshilfe, 1‐11.

World Health Organiza on (WHO), Mental Health Atlas, 2011, Democra c Republic of the Congo Ψ



Historically, reports of the experiences of refugees around the world have been and con nue to be profoundly compelling. An essen al component of that experience is the psychosocial impact resul ng from condi ons of refugee life that challenge survival. In this column, we a empt to do jus ce to the reality of refugee life and the emerging responses by psychologists to the needs of refugees. We first frame the extensiveness of refugees worldwide, then present a moving and provoca ve first person account of encountering a refugee camp and finally, discuss some emerging responses by psychologists to the trauma of what are so o en debilita ng circumstances.

The Status of Refugees Reports from the United Na ons High Commissioner for Refugees (UNHCR) indicate that as of 2013, there were over 10 million refugees worldwide, with more than half of them coming from Afghanistan, Iraq, and Somalia (UNHCR, 2012, 2014a).

According to a UNHCR report (2014a), the 1951 Refugee Conven on defines a refugee as someone who "owing to a well‐founded fear of being persecuted for reasons of race, religion, na onality, membership of a par cular social group or poli cal opinion, is outside the country of his na onality, and is unable to, or owing to such fear, is unwilling to avail himself of the protec on of that country (UNHCR, 2014b)." Forced displacement from one’s homeland to a host country is a global issue and since its incep on, the UNHCR has been tasked with providing protec on, assistance, and humanitarian aide to refugees worldwide.

While temporary refugee camps are has ly erected by non‐government organiza ons (NGOs) and local governments around the world, the news media tends to focus intensely on a few “hot spot” camps for refugees. Currently, news reports focus on temporary refugee camps in Jordan and Turkey, whose residents have fled warfare

in Syria and have fled incursions from ISIS/ISIL. During previous periods of armed conflict, the Darfur refugee camps in Sudan, were prominently featured in the news as were refugee camps for vic ms fleeing armed conflict in Kyrgyzstan. UNHCR (2012) professionals respond to “new emergencies in places such as Libya and Côte d’Ivoire, while addressing long‐standing displacement in and from countries such as Afghanistan, the Democra c Republic of the Congo, Iraq, Somalia, and Sudan” (p. 5). NGO and humanitarian professionals a empt to recognize and honor diversity among displaced popula ons including cultural, historical, gender, religious, and food prac ces. Living in a Refugee Camp “The refugees of concern to UNHCR are spread around the world, with half in Asia and some 28% in Africa. They live in widely varying condi ons, from well‐established camps and collec ve centres to makeshi shelters or living in the open” (UNHCR, 2014c). Have you ever wondered about the living condi ons in a refugee camp? What is the treatment of and hardships for children? …women? … disabled people? … elderly people? … families? Ms. Hadia Zarzour, a former member of Neal Rubin’s Division 52 student group, has translated observa ons of her friend, Ms. Suzanne Kawmieh, who volunteers me and services in a refugee camp in Syria. Hadia reports that Suzanne is Syrian and has been very ac ve assis ng Syrians in a refugee camp


UN MATTERS

By Juneau Gary and Neal S. Rubin, APA Representatives at the UN Department of Public In-formation, Column Co-Editors Juneau Gary, PsyD (APA main representa ve to DPI) is a Professor in the Department of Counselor Educa on at Kean University in New Jersey. Neal S. Rubin, PhD, ABPP (APA representa ve to DPI) is a Professor at the Illinois School of Professional Psychology of Argosy University in Chicago. Both are APA NGO Representa ves to the United Na ons Department of Public Informa on and are co‐editors of this column.

A First Person Account of the Refugee Experience: Identifying Psychosocial Stressors and Formulating Psychological Responses



located on the border of Syria and Jordan. We are including the transla on, with permission, and have made only minor editorial comments in order to improve the gramma cal flow and have not altered the content.

In Her Own Words: Suzanne Kawmieh as translated by Hadia Zarzour In early 2014, I took a short trip to the Syrian‐Jordanian border, specifically the Zaatari refugee camp (Jordan), for the first me. I had been working on various humanitarian projects related to Syria; however, the focus had not been the refugees, but

on those who were s ll in Syria. The Zaatari refugee camp is now the fourth largest city in Jordan and is home to over 150,000 Syrian refugees. A winter storm hit the camp the week before we arrived, flooding and collapsing all of the tents. Refugees were literally le homeless (or more accurately, tent‐less). What li le clothing and food supplies they had, were destroyed. Our trip was an emergency relief trip to provide winter jackets, food aid, portable hea ng units, and medical supplies.

The refugee camp is in the middle of nowhere ‐ the north Jordanian desert ‐ far from any city or inhabited area. Tall barbed wire fences surrounded the camp and guards would arbitrarily open and close the camp to incoming refugees, volunteers, or visitors. When we finally arrived at the camp, the guard would not allow us entry. We showed them our Syrian iden fica on and told him we want to visit rela ves. We tried many ways of persuading the 20‐something year old guard, who was empowered by his rifle, to let us enter. He would not. So, we sat against the fence on a dirt road and waited. Soon, luxury cars full of wealthy donors from Gulf States rolled up and the guard would wave them through. One a er another. Those of us who arrived on foot, were Syrian, and had nothing but our backpacks, were refused entry.

A man was also leaning against the fence next to me. His daughter was seated between us. She was young, about 7 years old. She asked for water; she was thirsty. He told her she had to be strong; there was no water. A li le while later, she asked again and received the same response. Yet again she asked, and finally her father told her he would ask the guard for some water. The guard mocked him and beat him with the bu of his rifle. I turned away and couldn’t look anymore. I couldn’t photograph or document what was going on, though I knew there was no way in hell it was legal to beat refugees for asking for water. The man’s wife begged them to let him go. Through her tears, I could hear her tell him they should go back to Syria. “Be er to die by bombs and snipers, but with dignity, than here.” Another luxury car approached. A passenger seated in the back rolled down his window and stuck out his camera and tried to take a picture of me ... si ng on the side of a fence on a dirt road, exhausted a er walking for so long, in my misery and filth. He wanted his cliché “poor refugee woman” picture. I wanted to spit in his face. I never felt so weak, so humiliated, so violated. I suddenly understood what it must be like to be on the other side of the camera: to have prying journalists want to capture your moment of despair and profit from it. Instead of people helping you out of your despair, they want to save it on their flash drives, show it at banquet dinners, and use it as a gimmick. I remembered what one young girl had told me previously, of how a French journalist had asked her to cover her face with a scarf and wanted to photograph her because she had blue eyes. Her mistrust and rage about opportunis c journalists now seemed quite mild.

Soon, another car approached the refugee camp … another wealthy donor … another foreigner. This one thought his dona on could buy him a wife because Syrian refugee women were so desperate these days. The young girls in the camp told me about these men ‐ how they would hide in fear that they would be spo ed. These men would “marry” a young girl and not pay a dowry, only to divorce her a week or so later. “Marriage” provided a religiously‐permissible cover for them to enjoy their vaca ons. We were finally allowed entry into the camp. I saw small bridal “shops” popping up. They displayed bridal wear, dresses, makeup, and costume jewelry. A young girl was being fi ed into a bright blue dress by her older sisters and mother. She didn’t want to marry the suitor; he was several years older. Her mother told her she would grow to love him when he cared for her. This was her cket out of the refugee camp and the squalor they were le in. She remained silent. They struggled to fit her into a dress she was praying wouldn’t fit.

The families of the girls weren’t cruel or profi ng off the marital exchanges. They just hoped the man would be able to provide their daughters with some semblance of security; something they didn’t have in their small tents. Incidents of sexual harassment, and even rape, were common in camps in which no law enforcement existed or method of defense was available.




The family from the bridal shop invited us back into their tent. We sat on a muddy floor drinking cloudy tea (from contaminated water). We realized we were from the same former village. We caught up on the past few years we had been apart and they also described their refugee experiences. Soon, other residents from our former village had gathered outside the crowded tent. They shared with us their hardships and pleaded that we do something … anything. They showed us an expired can of luncheon meat they were given as their food ra on for the week and how their children grew ill upon ea ng it.

One mother showed me her young son who was having “episodes” (i.e., outbursts) and asked me if I knew what was wrong with him; if there was anything I could do to help him. I felt my mouth go dry as I recognized that the boy hadn’t been able to forget his trauma c experiences. He could only scream to drown out memories of sounds and events. I knew we couldn’t do anything; we weren’t equipped with the necessary medica on and didn’t have a mental health professional on our team. I told the mother, “No, I’m sorry.”

A young girl took me aside to her tent and told me about the other girls who had been raped in Syria. How they were seized from their university campuses or homes. She described how they were inconsolable and had given up on life. Some had literally commi ed suicide. She told me about the physical and emo onal wounds they had; how their families were shamed; how they no longer had any sort of future in their tradi onal tribal families and home towns; how they were disowned. She then asked me if I knew any surgeons who could perform hymen reconstruc on for these young women. Perhaps they can put the rape out of their minds; perhaps they can pretend to be virgins, move on with their lives and marry. I told her I was not a health professional, I did not know. But would she be comfortable with me asking the doctors on our team? She refused. They were all men. Some of them knew her family. I couldn’t comprehend the severity of the damage, either physical or emo onal. I couldn’t refer her to anyone. I couldn’t do anything but cry. I felt paralyzed and responsible. These girls needed so much more than just reconstruc ve surgery, but this was a problem that reached beyond war to deep rooted tradi on, tribal affilia ons, and what the girls wanted and needed. I had to respect their wishes; they didn’t want men involved. Any men. Even men whom I knew would not treat them with anything less than gentleness and respect ‐ men who could help them heal. She gave me her phone number on a piece of paper and told me that if I came across anyone who could help, to please call ‐ somehow. I folded the small piece of paper with the Arabic numerals and placed it in my pocket. I can s ll hear her pleading with me not to forget them … not to forget her. I could s ll hear them pleading for a woman’s help with what, to them, was a woman’s problem.

As we le , we passed through a military checkpoint. Guards had their automa c weapons visible and one huge tank sat on the side. We turned and waved to the family and neighbors. They stood in a crowd. They weren’t allowed to leave the refugee camp. It’s like one big open air prison. They could only get so close to the checkpoint. Once we crossed, that was it. Our passports were returned and we le the camp. I couldn’t look back, I had to walk out and keep going down the dirt road. It was a long dirt road that led away from the barbed wire, the tragedies, the hushed pleas, and the expired food.

Psychosocial Stressors and Refugee Camps Although it is difficult to do jus ce to such a moving and evoca ve first person account, Suzanne’s personal narra ve highlights many compelling psychosocial issues of interest to interna onal psychologists (e.g., pre‐ and post‐migra on/rese lement stressors; effects of involuntary detainment within refugee camps; effects of limited opportuni es to par cipate in the host country’s ac vi es, such as employment or educa on; and effects of insecure housing and insecure residen al/immigra on status). Suzanne’s narra ve also highlights troubling issues of interest to clinical psychologists (e.g., PTSD, anxiety, suicide, vulnerability/powerlessness, depression, and effects of rape). Collec vely, these stressors have the poten al to exacerbate PTSD symptoms that have been found to be pervasive among refugees. (Drozdek, Kamperman, Tol, Knipscheer, & Kleber, 2013; Yakushko, Watson, & Thompson, 2008).

According to Kruse, Jaksimovic, Cavka, Woller, and Schmitz (2009), PTSD is the most common psychological disorder that has been studied among war refugees. Moreover, they and other researchers (e.g., ter Heide, Mooren, Knipsheer, & Kleber, 2014; Yakushko et al., 2008) assert that due to witnessing and experiencing (1) repeated exposures of war, violence, rape, and bombings, (2) torture, death, disappearance, and/or wrongful imprisonment of rela ves or loved ones, and (3) involuntary reloca on, complex PTSD is o en persistent and chronic, and might complicate the efficacy of treatment interven ons. Yakushko et al. (2008) offer some examples of refugees’ experiences, no ng “80% of Cambodian refugees reported losing a friend or family member, 20% of Vietnamese refugees reported exposure to major trauma with 5.5% repor ng imprisonment or torture, and 60% of Indochinese refugees repor ng some form of trauma with over one fourth repor ng having been tortured” (p. 170). In addi on to the experiences of overt trauma, most refugees arrive at a temporary refugee camp with limited personal possessions, having le photographs and keepsakes behind. Another stressor, therefore, becomes the possibility of “statelessness,” or being without a recognized legal status in a host country. Camp stressors (e.g., overcrowding, unsanitary condi ons, limited or non‐tradi onal food supplies, and transiency), along with feelings of helplessness and powerlessness, contribute to short term and long term emo onal distress, and eventually complicated PTSD, if not treated early (Yakushko).




Clinical Interven ons Trauma‐focused cogni ve behavior therapy (CBT) and eye movement desensi za on and reprocessing (EMDR) have proven to be effec ve psychological interven ons for Western clients who have experienced trauma but the evidence‐based efficacy for refugees residing globally is in its infancy and is under‐inves gated (ter Heide et al., 2014; Drozdek et al., 2013; Yakushko et al., 2008). A growing number of researchers (e.g., Kruse et al., 2009; Drozdek et al.; ter Heide et al.) agree that trauma‐focused, mul modal, mul ‐component interven ons that are also culturally adapted and linguis cally appropriate, are proving to be effec ve for refugees experiencing complicated PTSD. Increasingly, Western psychologists are learning to appreciate the rela onship between the collec vist nature of many of the refugees’ cultures with designing and implemen ng interven on models. Most psychological interven ons that are reported in the literature have occurred in se ngs in Western countries, a er refugees have rese led permanently, rather than within the temporary confines of refugee camps. Drozdek et al. (2013) have used group interven ons effec vely while Kruse et al. (2009) and ter Heide et al. (2014) have experienced posi ve outcomes with individual interven ons. We briefly discuss both types of interven ons.

Individual Interven ons with Refugees Krause et al. (2009) used an individual psychotherapeu c interven on with Bosnian refugees while implemen ng seven core elements (i.e., treatment rela onship, feelings of safety, psychoeduca on, cogni ve restructuring, progressive muscle relaxa on, skill building/regula on of affect, and self‐percep on/caring of oneself). ter Heide et al. (2014) report treatment success using EMDR on an individual basis with a refugee popula on, no ng “EMDR may be a suitable approach for refugees because it does not include homework assignments, may minimize language issues because speech is not always necessary, and has been found efficacious with pa ents from non‐Western cultural backgrounds” (p. 147). O o and Hinton (2006) and Schulz, Resnick, Huber, and Griffin (2006) have demonstrated the efficacy of CBT and adapted cogni ve processing therapy with refugee popula ons.

Group Interven ons with Refugees In the Netherlands, Drozdek et al. (2013) used a group interven on model to treat Iranian and Afghan refugees in a long term day treatment program for PTSD. Clients ranged in age between 18 years and 70 years and spoke Farsi or Dari. Their treatment model incorporated components of CBT with imaginal exposure, empowerment, and socially suppor ve interven ons as well as explora on of coping styles. Psychotropic medica on and non‐verbal therapies (e.g., art therapy, music therapy) were incorporated as adjuncts to group therapy. The non‐verbal therapies were effec ve with clients who experienced difficulty in the verbal expression of trauma c experiences. The short term and long term outcomes of this model were posi ve for the reduc on of PTSD, depression, and anxiety symptoms.

Stressors and Permanent Rese lement For those individuals and families who are fortunate enough to leave a temporary refugee camp and immigrate to a host country (typically a Western one) with the inten on of permanent se lement, other stressors arise as they relate to adjustment. These might include adjustments to new mores, addi onal rules, different languages, and atypical lifestyles as well as managing stressors arising from their insecure legal residency status and/or poten al for “statelessness” (Yakushko et al., 2008). The o en irreversible reloca on to a host country gives rise to the possibility of significant loss of and grief for rela ves, friends, neighbors, and the former lifestyle. Upon arrival in the rese lement country, a series of issues might impact adjustment. These issues might include personal health and mental health challenges due to torture, poverty, untreated war‐related injuries, unsanitary living condi ons in the temporary refugee camp, or an insecure immigrant status. These pre‐exis ng reloca on stressors, compounded by the new environment of the host country, along with a diminished social and legal status and any social oppression or prejudice arise from members of the new host country, will contribute to accultura on stress.

Interven ons to Facilitate Refugee Rese lement “Interven on work with immigrants must include considera ons of the psychosocial factors that influence immigrants’ experiences of stress and coping” (Yakushko et al., 2008, p. 174). Local psychologists and psychologists contracted by NGOs will provide therapeu c interven ons but must also collaborate with other professionals in order to provide a full complement of support and adjunct services to the refugee popula on in the new rese lement country. Gilbert (2009) and Yakushko et al. recommend that professionals examine each refugee’s individual and family resources for successful social, cultural, and economic integra on; explore family dynamics from the family’s cultural background including gender, age, disability, and household composi on; assess mo va on for adapta on which includes the acquisi on of the new language and lifestyle; evaluate problem‐solving and coping skills; and iden fy transferable



employment skills. (Con nued on page #)

All professionals are advised to take a long term perspec ve of the post‐migra on process in order to facilitate a refugee’s successful rese lement. This process includes providing culturally‐ and linguis cally‐appropriate short term and long term psychological services focused on PTSD symptom reduc on and cultural adapta on; advoca ng for bilingual interpreters, if necessary; understanding the host country’s refugee rese lement policies, prac ces, laws, and resources; facilita ng access to the country’s legal system, educa onal system, language classes, health care system, and employment services, among others, as well as loca ng adequate housing.

Conclusion By providing a first person account of the refugee experience, we hope we have offered an in mate, though disturbing, window into understanding the reality of what refugees typically encounter. Successfully confron ng mul ple and complex psychosocial stressors related to warfare, torture, rape, and forced disloca on of refugees require mul modal interven ons used within a culturally‐ and linguis cally‐appropriate context. Services may be provided by psychologists and other professionals to address the complexity of issues related to accultura ve stress. Yet, in spite of everyone’s best effort, not all outcomes will be posi ve. Gilbert (2009) asserts that NGO professionals face the possibility of encountering a lack of clarity in their role, confused demands, and difficulty in naviga ng complex poli cal situa ons in the host country. Gilbert con nues to assert, “These dilemmas are rarely discussed explicitly, but permeate every aspect of the refugee and counselor interac on (p. 50).” These are the types of challenges and condi ons that interna onal psychologists encounter and are learning to confront. References Drozdek, B., Kamperman, A., Tol, W., Knipscheer, J., & Kleber, R. (2013). Seven‐year follow‐ up study of symptoms in asylum seekers and refugees with PTSD treated with trauma‐focused groups. Journal of Clinical

Psychology, 70(4), 376‐387. doi: 10.1002/jclp.22035 Gilbert, J. (2009). Power and ethics in psychosocial counseling: Reflec ons on the experience of an interna onal NGO providing services for Iraqi refugees in Jordan. Interna onal Journal of Mental Health, Psychosocial

Work, and Counseling in Areas of Armed Conflict, 7(1), 50‐60. Kruse, J., Jaksimovic, L., Cavka, M., Woller, W., & Schmitz, N. (2009). Effects of trauma‐ focused psychotherapy upon war refugees. Journal of Trauma c Stress, 22 (6), 585‐592. doi: 10.1002/jts.20477 O o, M., & Hinton, D. (2006). Modifying exposed‐based CBT for Cambodian refugees with pos rauma c stress disorder. Cogni ve and Behavioral Prac ce, 13, 261‐270. Schulz, P., Resnick, P., Huber, L., & Griffin, M. (2006). The effec veness of cogni ve processing therapy for PTSD with refugees in a community se ng. Cogni ve and Behavioral Prac ce, 13, 322‐331. ter Heide, J.J., Mooren, T., Knipsheer, J., & Kleber, R. (2014). EMDR with trauma zed refugees: From experienced‐based to evidence‐based prac ce. Journal of EMDR Prac ce and Research, 8(3), 147‐156. UNHCR. (2012). The state of the world’s refugees: In search of solidarity. Retrieved from h p://www.unhcr.org/cgi‐bin/texis/vtx/home/opendocPDFViewer.html?docid=4fc5ceca9&query=state%20of%202012 UNHCR. (2014a). Know your numbers. Retrieved from h p://www.unhcr.org/pages/49c3646c11.html UNHCR. (2014b). Refugees. Retrieved from h p://www.unhcr.org/pages/49c3646c125.html UNHCR. (2014c). Refugee figures. Retrieved from h p://www.unhcr.org/pages/49c3646c1d.html Yakushko, O., Watson, M., & Thompson, S. (2008). Stress and coping in the lives of recent immigrants and refugees: Considera on for counseling. Interna onal Journal of Advanced Counseling, 30, 167‐178. doi:

10.1007/s10447‐008‐9054‐0 Special thanks to Ms. Suzanne Kawmieh and Ms. Hadia Zarzour for their insigh ul comments and contribu ons to this

column. Ψ



Global Networking Forum Series with The Chicago School of Professional Psychology

By Sally Leverty, APA Office of Interna onal Affairs (OIA)

APA is partnering with the Chicago School of Professional Psychology (TCSPP) to host a Global Networking Forum on the Washington, DC, campus. The second talk in the series, “Ebola Epidemic: What is the Role of Interna onal Psychology?” was given by Gregory Pappas, MD, PhD, whose interna onal career in public health and global health spans 30 years working in academia, government, and the private sector. Dr. Pappas was named Execu ve Director, Division of Health Sciences, of the Chicago School in October 2014.

Dr. Pappas began with an overview of the history of Ebola epidemics since 1976 to the present and spoke about how, despite the fact that the disease and mechanisms to prevent its spread are well understood, there is a global epidemic of anxiety and fear caused by the current outbreak. In the U.S., this fear was fueled by a number of things ‐ the round‐the‐clock media coverage following ini al reports of the first Ebola case in the country, the poli cal spin in the run up to the mid‐term elec ons, and ongoing underlying societal issues such as an erosion of confidence in authority and mistrust of science.

Accurate informa on is vital to dispel myths and improve people’s understanding of Ebola disease. Dr. Pappas commended APA for its statement on “Managing your fear about Ebola” (h p://www.apa.org/helpcenter/ebola‐fear.aspx), which provides informa on about how to limit anxiety and promote healthy behavior. In addi on to providing a suppor ve response, Dr. Pappas called on interna onal psychology to take a broader policy role to help make mental health a global priority. He cited a World Health Organiza on study of 58 countries that showed es mates of an overwhelming shortage (80%) of psychosocial care workers, par cularly in low and middle income countries where access to services is severely limited. Dr. Pappas also discussed the need in the U.S. to integrate public health and mental health and noted that there are currently few programs in public health that provide

educa on with an emphasis on mental health. Ψ

2015 APA Award for Distinguished Contributions to the International Advancement of Psychology Walter J. Lonner, PhD (Professor Emeritus of Psychology at Western Washington University)

Since the mid‐1960s, Lonner has been engaged in cross‐cultural psychological research, much of it seminal and ground‐breaking. He has published over 100 books, book chapters, and journal ar cles. These include significant works such as the six‐volume, Handbook of Cross‐Cultural Psychology, Cross‐Cultural Research Methods, Counseling across Cultures, and Field Methods in Cross‐Cultural Research and Psychology and Culture. In 1970, Lonner founded the Journal of Cross‐Cultural Psychology (JCCP) and served as its editor for many years. He was also a founding member of the Interna onal Associa on of Cross‐Cultural Psychology (IACCP), and has served as its president and in other roles over the years. Although he has re red from the University of Western Washington (where he co‐founded the Center for Cross‐Cultural Research in 1969), he con nues to be ac ve in IACCP and with JCCP and other research.

2015 APA International Humanitarian Award Sunil Bha a, PhD (Department of Human Development, Connec cut College)

Using his knowledge of qualita ve and ethnographic methods, Sunil Bha a has formed alliances with over a dozen community partners and NGOs in the U.S. and in his na ve city of Pune, India, to provide the urban poor with access to clean sanita on and private toilets. He has brought a taboo subject – open defeca on – into the spotlight to show how lack of sanita on is connected to psychological constructs of dignity, humilia on, and safety. His collabora ve, community‐based approach has created a sustainable program that has been shown to improve physical and psychological health, prevent the spread of disease, and provide security, privacy, dignity, and reduced fear of sexual assault for those living in the vast slums of Pune, Sangli,

and Miraj, India. Ψ

2015 APA INTERNATIONAL AWARDS



By Nabil Hassan El‐Ghoroury, PhD, APA Graduate Students Office (APAGS)

APA sponsored its third APA Interna onal Learning Partner group trip to Cuba from November 9‐16, 2014. This trip included 12 psychologists from around the U.S., with former APA President Suzanne Benne Johnson as our group leader. We met with psychologists from the Cuban Ministry of Health and la Sociedad Cubana de Psicología de la Salud (Cuban Society of Health Psychology), and visited a center for individuals with developmental disabili es, a new neuroscience facility, a local doctor’s office and polyclinic. In addi on, we a ended the VII Conferencia Internacional de Psicología de la Salud (7th Interna onal Conference on Health Psychology), where most group members gave a presenta on on their topics of interest in health psychology.

This trip was enlightening on so many levels. First, it was incredible seeing the Cuban health care system and its reach into the community. We learned that there is a primary care doctor’s office for approximately every 1000 to 1200 residents embedded within the community; in Havana, this translates to a doctor’s office every 2‐3 blocks, but for rural areas this might be for a whole community. The polyclinic is a larger clinic that holds a variety of special es, and there is a polyclinic for about every 40 doctor’s offices. The polyclinic provides a wide number of services, including educa on to brand new parents, assessments of psychological

condi ons, dental care, rehabilita on services, and other interven ons.

Even be er than seeing the medical facili es was learning how psychology was integrated into the health care system. Psychologists work at all levels of the health care system, from the doctor’s offices to the polyclinics to specialty ins tutes for specific condi ons, such as cancer. Psychologists are trained at medical schools, alongside physicians in training. Psychologists in Cuba seem to get along well with their medical colleagues; they do not have the same conflicts that psychologists in the US may have with psychiatrists or other physicians.

As a health psychologist, I appreciated hearing about the focus on preven on as a public health strategy in Cuba. Because of limited medical resources, Cuba has placed much emphasis on preven on rather than ter ary care services. One key preven on strategy has been to provide ongoing services to pregnant women and to young children. This preven on approach has resulted in a lower infant mortality rate in Cuba than the U.S. (World Bank, 2014). This maternal‐child outreach does not end at birth; on our trip to the polyclinic we were able to see a mother being trained in parent‐child interac on by an educator.

The Cuban Neuroscience Center (CNEURO) was par cularly impressive. One of several advanced science and technology centers in Havana, the researchers there conduct world‐class research in neurotechnology, brain mapping, cogni ve neuroscience, and neurological and sensory disorders. Its explicit goal is to link brain research with public health needs. CNEURO, which contains a variety of advanced equipment, recently moved into a large, renovated building. To a greater degree than we saw at other Cuban health and research organiza ons, CNEURO scien sts have collabora ons and communica ons with colleagues around the world.

At the conference, I was able to hear an overview of an innova ve program developed in Cuba that integrates dance and

PSYCHOLOGY IN CUBA

APA group with Cuban Society of Health Psychology colleagues at the Ministry of Health.



movement with psychology, called psicoballet (psycho‐ballet). Working with psychologists and professional dancers, children and adolescents use dance to improve self‐esteem, learn skills in self‐regula on, self‐discipline, coopera on, and socializa on. Psicoballet started in Cuba in 1973 for children and adolescents with behavioral disorders (both internalizing and externalizing), and now includes individuals with developmental disabili es, vision and hearing impairments, adults, and the elderly. Par cipants learn a variety of dances and their confidence improves remarkably as they con nue in the program. At the conference, we were treated to the performances of several groups of psicoballet performers, who enjoyed dancing for the conference a endees.

At the same me that we were learning about the emphasis on preven on strategies, it was intriguing to see the amount of smoking that was occurring at the conference. To its credit, the Ministry of Health has many public educa on efforts to reduce the level of smoking in the country, including posters at all the clinics, stronger warnings than the US on packaging, and public service announcements on television. Furthermore, smoking indoors is technically against the law. However, at this conference, focused on health psychology, there was a significant amount of smoking both inside and outside the conven on center. Smoking was reinforced by easy access (a cigar store was located in the set of stores that connected the hotel and conven on center; the snack bar sold tobacco products in addi on to coffee and snacks), implied support (by the availability of ash trays in the conven on center hallways), and modeling (in that many individuals were smoking in the conven on center). The level of smoking demonstrated that there s ll is room for improvement in the outreach to reduce smoking and improve public health.

We learned that the impact of the U.S. embargo on Cuba is pre y devasta ng, and has a significant impact on the health care system. The Neuroscience Center had a difficult me purchasing an MRI machine because of the embargo. The embargo has made the Cuban currency worthless outside of Cuba, resul ng in a shortage of dollars to be able to purchase necessary goods, including medicines. Cuba has had to develop their own vaccines because of lack of access to U.S. pharmaceu cals. Psychologists lack access to tes ng instruments because most psychological tests are published by U.S. companies, or they lack funds to purchase them. It was apparent to all of us in a endance that the U.S. embargo of Cuba should be li ed.

Overall, this was an incredibly eye opening trip. It was inspiring to see how

psychologists can be integrated in a medical system. Cuban psychology can

serve as a role model for the U.S. about how to work in primary care. I am

grateful to have had the opportunity to visit Cuba, learn about their health

care system, and hear some of their interes ng applica ons of psychology.

September 17-19, 2015 Prague, Czech Republic

Web: http://http://www.wpforum.eu/



International Book Review: Selected Review from PsycCRITIQUES The book review reprinted here is courtesy of PsycCRITIQUES editor Danny Wedding. PsycCRITIQUES is an online journal that provides reviews of books, monographs, films, and other productions in psychology stretching back to 1956. Readers can also access selected reviews and discuss books important to the science and profession of psychology by visiting the PsycCRITIQUES blog at psyccritiquesblog.apa.org. For more information see www.apa.org/psyccritiques. If you are interested in reviewing, please contact editor Danny Wedding at [email protected].

The Bucharest Early Interven on Project:

Conver ng Common Sense Into Sta s cal Significance

A review of

Romania’s Abandoned Children: Depriva on, Brain Development, and the

Struggle for Recovery

By Charles A. Nelson, Nathan A. Fox, and Charles H. Zeanah

Cambridge, MA: Harvard University Press, 2014. 402 pp. , $29.95

Reviewed by Leafar F. Espinoza

PsycCRITIQUES CONTEMPORARY PSYCHOLOGY: APA REVIEW OF BOOKS American Psychological Association

Although the roots of psychology can be traced back a few thousand years to Greek philosophers such as Socrates, Plato, and Aristotle, psychology as a science is rela vely new. It was not un l perhaps 150 years ago that advances toward establishing psychology as a science began to be made. Wilhelm Wundt developed the first psychology laboratory in 1879, and, although introspec on (internal percep on) was used to inves gate thoughts, feelings, and emo ons, it was used systema cally and methodically (McLeod, 2008). Therea er, the empirical ball was passed on to behaviorists, who used controlled laboratory experiments, and cogni ve psychologists, who con nued developing a scien fic approach to study human cogni ons, emo ons, and behaviors. Being the fledgling science that it is, psychology has a number of dubious and controversial studies to its name—those associated with Stanford, Li le Albert, Harlow, and Milgram, to name a few. A notorious study never published in a peer‐reviewed journal is Johnson and Tudor’s “Monster Study.” In 1939, Wendell Johnson and Mary Tudor at the University of Iowa placed 22 orphan children in experimental and control groups. There were three groups: (a) normal disfluent children who were told they stu ered and it was bad, (b) stu ering children who were told they were good speakers, and (c) a normal disfluent control group. Essen ally, the researchers tried to induce stu ering in healthy children and to see whether telling stu erers that their speech was fine would produce a change. The children receiving “nega ve speech therapy” were beli led for every speech imperfec on and were told that they were stu erers. Many children who received this nega ve speech therapy suffered nega ve psychological effects, and some retained speech problems for the rest of their lives (“Monster Study,” n.d.). Of the controversial studies men oned above, the most relevant to this review is Johnson and Tudor’s, which used (ques onable) random assignment to control and experimentalgroups. Randomized controlled trials (RCTs) are considered the gold standard for a clinical trial and are o en used to test efficacy and effec veness of interven ons as well as adverse effects. They are quan ta ve, compara ve, controlled experiments in which treatment effect sizes may be determined with




less bias than in observa onal trials (Stolberg, Norman, & Trop, 2004). Romania’s Abandoned Children: Depriva on, Brain Development, and the Struggle for Recovery summarizes more than 10 years of research on the adverse effects of the ins tu onaliza on of children on cogni ve and behavioral development. The popula on for the study includes the many children who were the direct outcome of Romanian dictator Nicolae Ceauşescu’s pronatalist measures and economic policies. In 1966, Ceauşescu outlawed contracep on, forbade abor on, and taxed families that produced fewer than five children, increasing both birth and poverty rates. Because many families could not afford to keep all the children they were coerced into having, Ceauşescu expanded a network of ins tu ons where the state vowed to raise abandoned children—implicitly endorsing child abandonment (Nelson, Furtado, Fox, & Zeanah, 2009). A er Ceauşescu’s violent overthrow in 1989, countless orphanages containing thousands of children whose families were unable to support them were uncovered. Without exis ng alterna ves, the children had been placed in orphanages with minimal medical and social services, resul ng in high mortality rates and developmental disabili es (Morrison, 2004). The Bucharest Early Interven on Project (BEIP) is a joint collabora on between researchers at Tulane University, University of Maryland, and Boston Children’s Hospital examining the mul ple long‐term effects of profound early depriva on in a child’s life. The study, which began in 2000, was conducted in Bucharest, Romania, and included nonins tu onalized children (control group) and ins tu onalized children. Ins tu onalized children from many facili es were screened, and 136 children between ages six months and 31 months (M = 22 months), without preexis ng medical condi ons, were chosen. Of this ins tu onalized sample, 68 were randomly assigned to remain in the ins tu on, and 68 were assigned to foster care. Randomiza on is considered the most powerful experimental design in clinical trials: With other variables equal between groups, on average, any differences in outcome can be a ributed to the interven on (Sullivan, 2011). Notably, of the children chosen to remain in ins tu ons, many of them were not orphans and had families to which they could return. Throughout the BEIP, the following areas were assessed: physical development, language, social func oning/social‐emo onal development, environment, cogni ons, temperament, a achment, brain func on, and mental health problems. Considering the extent to which children were deprived of care and a en on in ins tu ons in Romania at the me, the results come as no significant surprise that these ins tu onalized children demonstrated deficiencies in several areas, including physical growth, IQ, brain development, and emo onal/behavioral development. Researchers were able to determine that, in addi on to preexis ng gene c vulnerabili es and adverse pre‐ or perinatal experiences, many of the abnormali es seen were due to ins tu onal rearing. Indeed, one of the most shocking findings was the detrimental effect that the absence of basic social interac on had on children’s overall physiological and psychological func oning. Ins tu onal caregiving involved having caregivers with li le training, “assembly‐line” caregiving with minimal one‐on‐one interac on, youngsters who were ignored and uns mulated for virtually all of their awake hours, frequent staff rota ons that made it difficult for the children to develop meaningful rela onships with any single caregiver, and no adult–child rela onships that were reliably responsive to a child’s individual needs (Center on the Developing Child at Harvard University, 2012). In sum, a child deprived of a en on, affec on, and s mula on suffers in many ways, both physically and psychologically. However, the BEIP research had promising results and demonstrated that placement in foster and family care resulted in significant improvements in the aforemen oned areas, with the age at which a child was placed in family care being a significant predictor of outcome—the younger, the be er. One ethics professor, however, has brought up some interes ng ethical ques ons about the research: In their desire for the methodological rigor of a randomized controlled trial, had the BEIP researchers actually harmed children? In an ar cle in Bioethics Forum, Joseph Fins, professor of medical ethics and chief of the Division of Medical Ethics at Weill Cornell Medical College, asked whether it might not have been possible to have put a me limit on the dura on of each child’s exposure to the orphanage and to follow everyone subsequently in foster care. He also ques oned whether perhaps the same results could have been obtained through a regression analysis (Fins, 2013). Fins went on to state that, long before the data were collected, a key outcome was knowable. Hence, the researchers were not in a state of equipoise. According to Grady (2008), clinical equipoise is the ethical jus fica on to begin an RCT when there is a lack of convincing evidence that one of two or more interven ons is superior in its therapeu c efficacy, safety, or clinical usefulness. Clinical equipoise is genuine uncertainty within the expert medical community about the preferred treatment.




In an ethics commentary, Rid (2012) appeared to have a similar opinion, asking whether the finding that children placed in foster care have be er outcomes than those placed in ins tu ons is a new one. However, Rid con nued to say that the BEIP clearly had instrumental value for improving the health of abandoned children in Romania, par cularly because Romanian policy makers disagreed about the benefits of foster care. Further, Rid made the point that perhaps our understanding of the social value of research should be not only broadened to include unresolved scien fic, clinical, or public health problems but also extended to include states of prac cal—not merely scien fic—uncertainty.

It seems that one of the more salient ethical ques ons regarding this research is the following: How long should the children have been allowed to remain in ins tu ons in order for sufficient evidence of its detrimental effects to be collected? Was there any room to push for shorter ins tu onal stays for the experimental groups and s ll lobby for policy changes? According to Nelson, Fox, and Zeanah in Romania’s Abandoned Children, in studies of new drugs, if preliminary results indicate that a par cular drug is clearly more effec ve than a placebo, the trial can be stopped and the drug made available to everyone, even when the RCT has not been completed. However, the authors state that a stop rule was not an op on for the BEIP because of the high cost of foster care. The researchers said that they simply did not have the funds to remove the 68 children randomized to care as usual from the ins tu ons and place them into foster care.

In a response to Fin’s cri que of the study, Nelson, Fox, and Zeanah (2013) also stated that, if they had not conducted the study, all of the children would have grown up in the toxic environment of an ins tu on. The authors have touted the study’s influence on the many policy changes regarding the ins tu onaliza on of children in Romania, such as banning the ins tu onaliza on of children under the age of two in 2004 and the drama c references expansion of government foster care. Finally, the authors clarified that the study was not aimed at determining whether ins tu ons are bad but at discovering whether removing children from ins tu ons and placing them into families could remediate the deficits incurred by previous early experiences.

As men oned earlier, psychology as a science has a rela vely short history, but there is no doubt that it has served to improve people’s quality of life in many ways. Indeed, despite controversy and in the face of harsh cri ques, these par cular psychological scien sts obtained irrefutable, empirical data in an effort not only to be er understand the effects of ins tu onaliza on on the child but also to effect policy changes. However, as with many other historical psychology

studies, we’re grateful for the informa on, but let’s just maybe not do that again. Ψ References Center on the Developing Child at Harvard University. (2012). The science of neglect: The persistent absence of responsive care

disrupts the developing brain (Working Paper No. 12). Retrieved from h p://developingchild.harvard.edu/resources/ reports_and_working_papers/working_papers/wp12/ Fins, J. J. (2013). Romanian orphans: A reconsidera on of the ethics of the Bucharest Early Interven on Project. Bioethics Forum:

Diverse Commentary on Issues in Bioethics. Retrieved from h p://www.thehas ngscenter.org/Bioethicsforum/ Post.aspx?id=6581&blogid=140 Grady, C. (2008). Clinical trials. In M. Crowley (Ed.), From birth to death and bench to clinic: The Has ngs Center bioethics briefing

book for journalists, policymakers, and campaigns (pp. 21–24). Garrison, NY: Has ngs Center. McLeod, S. (2008). Psychology as a science. Simply psychology. Retrieved from h p://www.simplypsychology.org/science‐

psychology.html Monster Study. (n.d.). In Wikipedia. Retrieved July 19, 2014, from h p://en.wikipedia.org/wiki/Monster_Study Morrison, L. (2004). Ceauşescu’s legacy: Family struggles and ins tu onaliza on of children in Romania. Journal of Family History,

29, 168–182. h p://dx.doi.org/10.1177/0363199004264899 Nelson, C. A., Fox, N. A., & Zeanah, C. H. (2013). Romanian orphans study: Inves gators respond to ethical ques ons. Bioethics

Forum: Diverse Commentary on Issues in Bioethics. Retrieved from h p://www.thehas ngscenter.org/Bioethicsforum/ Post.aspx?id=6602&blogid=140&terms=Nathan+Fox+and+%23filename+*.html Nelson, C. A., III, Furtado, E. A., Fox, N. A., & Zeanah, C. H., Jr. (2009). The deprived human brain: Developmental deficits among

ins tu onalized Romanian children—and later improvements—strengthen the case for individualized care. American Scien st, 97, 222–229. h p://dx.doi.org/10.1511/2009.78.222

Rid, A. (2012). When is research socially valuable? Lessons from the Bucharest Early Interven on Project: Commentary on a case study in the ethics of mental health research. Journal of Nervous and Mental Disease, 200, 248–249. h p://dx.doi.org/

10.1097/NMD.0b013e318247d124 PsycINFO → Stolberg, H. O., Norman, G., & Trop, I. (2004). Randomized controlled trials. AJR: American Journal of Roentgenology, 183, 1539–

1544. h p://dx.doi.org/10.2214/ajr.183.6.01831539 Sullivan, G. M. (2011). Ge ng off the “gold standard”: Randomized controlled trials and educa on research. The Journal of Graduate Medical Educa on, 3, 285–289.



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