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The Harvard Program in Refugee Trauma (HPRT), originally founded at the Harvard School of Public Health, is a multi-disciplinary program that has been pioneering the health and mental health care of traumatized refugees and civilians in areas of conflict/post-conflict and natural disasters for over two decades. Its clinical program serves as a global model that has been replicated worldwide. HPRT designed and implemented the first curriculum for the mental health training of primary care practitioners in settings of human conflict, post-conflict, and natural disasters. Its training activities have been successfully conducted in Bosnia-Herzegovina, Cambodia, Croatia, Japan, and the United States. HPRT’s landmark scientific studies have demonstrated the medical and mental health impact of mass violence as well as the cultural effectiveness of its clinical treatment and training programs. Working closely with Ministries of Health throughout the world, HPRT has developed community-based mental health services primarily in existing local primary health care systems. It has also successfully established linkages to major foreign university settings. HPRT’s bicultural partnerships with international collaborators have resulted in culturally effective and sustainable programs that rely primarily on local human resources and indigenous healing systems. In order to achieve its mission, memorandums of agreements have been signed between HPRT and universities in Bosnia-Herzegovina, Italy, Japan, and Thailand. As a university-wide program, HPRT has access to the full resources and talents of Harvard University, including the Medical School (HMS), the School of Public Health, the School of Education, and the Massachusetts General Hospital (MGH). HPRT is currently administered by MGH, one of America’s oldest and most prestigious hospitals, which is a major teaching hospital of HMS.

CLINICAL ACTIVITIES
HPRT’s model, which focuses on the identification and treatment of extreme trauma (natural and human-made) through local indigenous healing systems, primary care, and community organizations, has been replicated throughout the world. HPRT founded its clinical program in December 1981 in Boston, Massachusetts. This clinic, the Indochinese Psychiatry clinic (IPC), was one of the first in the United States to care for the mental health needs of refugees; it soon matured into a major clinical center at Harvard Medical School. IPC’s clinical and evaluation research demonstrated that refugees who have experienced extreme trauma and dislocation can recover and return to normal productive lives. HPRT’s clinical activities were eventually extended to traumatized populations living in refugee camps (e.g., Cambodian refugees in Thailand), civilians in conflict societies (e.g., East Timor), civilians living in post-conflict societies (e.g., Bosnia-Herzegovina), and survivors of natural disasters (e.g., Kobe, Japan). Currently, HPRT is providing training and technical assistance to health and mental health providers caring for the survivors and the families of victims of September 11th in New York City.

HPRT is currently in the third year of a four-year grant from the Office of Refugee Resettlement to provide community-based clinical care for torture survivors residing in Massachusetts. HPRT clinicians are working on-site at primary health care centers and mutual assistance associations to screen and evaluate patients, and to provide consultation/liaison to primary care providers. HPRT is also collaborating with asylum attorneys to arrange mental health evaluation and treatment for their clients. This initiative, nicknamed “IPC+”, represents the evolution of IPC’s capacity to offer evaluation and treatment for individuals and families who have survived mass violence, including torture.

TRAINING ACTIVITIES
HPRT’s training activities have been extensive over the past two decades. Through IPC, HPRT provided the first clinical training in the United States on culturally accurate assessment and treatment of traumatized persons to a group of primary care physicians and mental health practitioners. Over the past 22 years, HPRT has trained thousands of persons from the major healing traditions in the United States and abroad. These practitioners include those from: 1) medicine and psychiatry; 2) traditional healing; 3) social service agencies; 4) UN and non-governmental organizations (NGOs).

In 1991, HPRT first trained a group of refugee survivors on the Thai-Cambodian border to provide mental health assistance to their fellow refugees. After the Cambodian elections in 1992, HPRT was invited by the Ministry of Health (MOH) of the Royal Cambodian Government to initiate a pilot community mental health project in Siem Reap Province, the site of the historic Angkor Wat temples. Following this invitation, HPRT developed the first community mental health clinic in Cambodia using Siem Reap’s primary health care system. Over the past 6 years, this clinic, staffed entirely by local residents, has treated over one thousand mentally ill patients.

After the Siem Reap clinic was established, the Cambodian Ministry of Health asked HPRT to train 100 primary care physicians throughout Cambodia’s 21 provinces. This effort transferred necessary mental health skills, knowledge, and behaviors to more than 10% of Cambodia’s primary health care system. For the first time, highly vulnerable groups traumatized by war and poverty, such as children/teenagers, widowed women, land-mine victims, and those plagued by chronic depression/PTSD, were able to receive culturally effective treatment within their local communities.

In Cambodia, HPRT perfected its training and technical assistance approach through its successful implementation of a bicultural model, which emphasizes local as well as Western mental health diagnoses (i.e, folk diagnoses and the DSM, respectively) and healing approaches through the local primary health care system. HPRT always places emphasis on the training and supervision of practitioners in rural and remote communities. The primary goals of HPRT’s trainings are to reduce physical and mental suffering, reduce functional disability, and return the patient to normal, productive social and economic lives within their local communities and families.

In 1995, HPRT’s training approach developed in Cambodia was adapted to help the medical and psychiatric practitioners caring for traumatized persons during the conflict in the Balkans. With the collaboration of local experts from Croatia and Bosnia, HPRT designed a curriculum and trained almost one hundred primary care practitioners from both countries. An extensive one-year training of Croatian and Bosnian mental health practitioners followed. Both trainings culminated in a regional meeting in Dubrovnik, Croatia in June 1998, where experts, practitioners, and policy makers assembled to discuss the lessons learned from HPRT’s recent training experiences in the region. The Dubrovnik meeting led to HPRT entering Bosnia on a World Bank-funded project through the support of Bosnia’s MOH. Over the past four years, HPRT and its Bosnian colleagues have established a training model that is being replicated throughout Bosnia and has been accepted by the region’s Stability Pact. This model includes a methodology, curriculum, and training approach that was successfully administered by HPRT to almost all primary care practitioners (n=105) in Middle Bosnia Canton, which is famous for its intensity of local ethnic violence and devastation. Concurrently with its activities in Middle Bosnia Canton, HPRT produced a curriculum on the care of traumatized persons that is now being integrated into Bosnia’s three medical schools (Sarajevo, Tuzla, Mostar), as well as its faculties of social work (Sarajevo), philosophy and psychology (Sarajevo), and the Franciscan Theological Seminary.

In the wake of September 11, 2001, HPRT was recruited by the U.S. Government to devise a similar training curriculum to provide assistance to PCPs caring for the survivors and families of victims of the World Trade Center attacks. HPRT has also developed a statewide training for local neighborhood health centers in Massachusetts and the tri-state region of New York.

SCIENTIFIC INVESTIGATION
In the mid 1980′s, HPRT developed the first valid and reliable screening instruments for measuring depression and trauma-related psychiatric disorders such as posttraumatic stress disorder (PTSD) in refugee populations. These instruments, such as the Harvard Trauma Questionnaire (HTQ), have been translated into over thirty languages and are currently being used worldwide.

HPRT’s clinical and research experience with traumatized Southeast Asian refugees led to the first large-scale epidemiological study of the impact of mass violence on civilian populations. This study, conducted in 1990 in the Thai-Cambodian refugee camp known as Site Two, focused on the assessment of the impact of mass violence on health, mental health, and disability. The refugees surveyed had experienced an average of 16 major trauma events, such as torture or rape, and had demonstrated high levels of emotional distress. More than 70% of those surveyed reported symptoms of major depression. One of the most salient findings was that the majority of this population, in spite of high levels of trauma, was engaged in economically productive activitiy. This economic activity occurred despite the reality that they were forbidden to legally work or farm for more than ten years of confinement in Site Two.

A follow-up investigation was conducted among a resettled Site Two Cambodian community in Lynn, Massachusetts in 1993 and 1994. Although these resettled refugees reported comparable levels of trauma to the respondents in the original Site Two study, they revealed lower levels of emotional distress and higher levels of social disability and economically unproductive activity. In 1998, a third survey was conducted on a non-traumatized Cambodian population indigenous to Thailand. A fourth investigation will be conducted in Siem Reap Province in Cambodia in late 2003. The analysis and cross-comparison of these four large datasets (n=4000), of a population devastated by mass violence and now embarking on reconstruction, will provide new and unique empirical insights into the relationship between trauma, health, and disability. Since these studies have focused on major aspects of social and economic functioning, they will continue to provide invaluable data for development and reconstruction policy.

Based upon its original Site Two study, in 1996 HPRT conducted a longitudinal study of Bosnian refugees. This landmark study is the first to follow the impact of trauma on the mental health of refugees over time. The Bosnian study included extensive evaluation of the socio-economic outcomes and risk factors of Bosnian refugees living in Croatia who were preparing for repatriation. The baseline study (1996) and subsequent three-year follow-up (1999) were published in the Journal of the American Medical Association in 1999 and 2001 respectively. In this population, depression and PTSD comorbid with depression were found to be unremitting, disabling, and associated with premature death.

Finally, HPRT is in the second year of a four-year NIH investigation of brain injury in Vietnamese-American detainees exposed to violence in re-education camps before arriving in the U.S. in the 1990s. This study will concern itself with the relationship between head injury and disability. It combines epidemiological survey methods with a case-controlled study of torture survivors using state-of-the-art neuroimaging techniques at Harvard’s brain imaging center.

POLICY
HPRT has established mental health policy for traumatized refugees through collaborations with national and international organizations. Nationally, HPRT has worked with the United States Office of Refugee Resettlement and the National Institute of Mental Health. HPRT, in its role as a collaborating center for the World Federation for Mental Health (WFMH), set the refugee mental health and human rights policies for WFMH. WFMH was founded in 1948 as an international organization to advocate for the mental health rights and needs of citizens throughout the world. The former Secretary General of WFMH, Dr. Eugene Brody, has been a senior consultant to HPRT since 1988. WFMH has national chapters in more than one hundred countries. It is the major nongovernmental organization consulting to the United Nations on mental health and human rights. Through its affiliation with WFMH, HPRT established an international network of refugee trauma centers. HPRT’s director, Dr. Richard F. Mollica, chaired WFMH’s Committee on Refugees and Migrants for over ten years. This committee successfully realized a memorandum of agreement with UNHCR. The parties to this memorandum agreed to work toward the integration of mental health into UNHCR’s humanitarian assistance programs.

Along with UNHCR and other European organizations, HPRT also helped formulate a document calledThe Utrecht Guidelines on the Evaluation and Care of Victims of Trauma and Violence. These guidelines have been widely distributed in the republics of former Yugoslavia and have been the basis of psychosocial assistance in that region. Through recent fieldwork in Bosnia-Herzegovina, Croatia, and Cambodia, HPRT has collaborated with their respective government health ministries to plan national mental health policy, which aids in the recovery and reconstruction of communities devastated by mass violence.

Since 1995, HPRT also played a major role in evaluating and recommending psychosocial assistance to the resident populations devastated by the Kobe earthquake in Japan. Immediately after the earthquake, which devastated the region and left more than 500,000 persons homeless and 5,000 persons dead, HPRT and its Japanese colleagues entered Kobe to provide assistance. An initial needs assessment led to the development of the first culturally valid screening instrument for Japanese earthquake survivors. For over six years HPRT has provided high-level consultation to local and national policy makers in Japan. In 1997, the Mayor of Kobe and other Kobe officials participated in a major scientific and policy meeting hosted by HPRT and Waseda University that led to the Tokyo Guidelines for Trauma and Reconstruction.

In 1999, HPRT’s staff provided technical assistance to mental health planners in East Timor. One dilemma for international policy makers is that they do not have a scientific methodology for assessing and responding to the political, cultural, and social impact of extreme trauma in the life of civilian populations. In May 1997, HPRT, in conjunction with Waseda University’s Institute for Asia Pacific Studies (WIAPS), organized an international symposium on trauma and reconstruction. Scientists, scholars, and policy experts from Japan, the United States, Cambodia, Croatia, and Bosnia-Herzegovina participated in this working symposium. This meeting, which took place in Tokyo, Japan, addressed the critical issue of economic and social recovery of societies extensively damaged by human and natural disaster. The proposals that emerged from this meeting were organized into a document that has been widely circulated to the UN, governmental, and humanitarian assistance agencies. This document, Tokyo Guidelines for Trauma and Reconstruction, presents new principles and approaches to the recovery of traumatized communities worldwide.

In 2001, HPRT’s director, Dr. Richard F. Mollica, was selected by the U.S. Fulbright Commission as a New Century Scholar (NCS). NCS consists of thirty of the world’s leading public health experts with 60% of NCS members coming from the developing world. Through NCS, in collaboration with the Bosnian MOH, HPRT convened a pilot meeting in Sarajevo of MOH officials from post-conflict societies in Asia, Africa, Latin/Central America, Europe, and the Middle East in September 2002. Out of this unique conference emerged an historic mission to create a global Mental Health Action Plancapable of using science-based policy and practices in culturally diverse communities to generate the healing and reconciliation of traumatized populations. This mental health action plan is foreseen as having a major new role in socio-cultural and economic development, as well as reconciliation.

In December 2004, HPRT hosted in Rome, Italy Project 1 Billion, the world’s first meeting of Ministers of Health from post conflict countries on mental health policy and recovery to create and disseminate the world’s first Global Mental Health Action Plan and the Book of Best Practices. This meeting was part of HPRT’s mission to maximize a scientific and culturally valid approach and methodology to reduce suffering and disability, and increase resiliency for the more than 1 billion survivors of mass violence worldwide.

Out of the Project 1 Billion meeting emerged the Global Mental Health: Trauma and Recovery Mastery Certificate Program (GMH program). This program was founded at the request of the Ministries of Health to build mental health capacity in post-conflict settings worldwide. It is partially supported by the Fogarty International Center at National Institute of Health and completed its first year of training in May 2007; and is completing its third year in May 2009. One hundred and fifty trainees who have worked in over 40 countries will have successfully completed the GMH program in 2009. This training has included medical and psychiatric experts from the Sudan, Ethiopia, Croatia, Democratic Republic of Congo, and Iraq. The program utilizes faculty members who are world renowned experts in their fields to educate and supervise GMH trainees in a blended learning environment that includes 2 weeks of face to face training in Italy followed by 20 weeks of web-based learning. The GMH program has introduced many innovations in learning and capacity building in collaboration with the Harvard Graduate School of Education.

Over its 25 year history HPRT has received many awards and commendations including the Human Rights Award from the American Psychiatric Association. HPRT has contributed to over 160 scientific publications in major journals such as: Journal of American Medical Association (JAMA), New England Journal of Medicine (NEJM), and Scientific America. In June 2002 HPRT’s work was aired on the ABC News Special “Nightline.” In December 2006, Harcourt Press published for the general public “Healing Invisible Wounds: Paths to Hope and Recovery in a Violent World” a book written by the director of HPRT Dr. Richard F. Mollica highlighting the work of the group over its 25 year history. HPRT’s scientific instruments and model have been replicated worldwide. HPRT continues to advance the scientific and culturally sensitive care of survivors of violence today as well as contribute to the prevention of new waves of mass violence in the future.

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