The Harvard Program in Refugee Trauma’s (HPRT’s) scientific and clinical methods grew out of research traditions in phenomenological philosophy, psychiatric epidemiology, and the women’s oral history movement. Scientific approaches from each of these three research traditions were integrated to create a new science of refugee mental health. In the early 1980s, little empirical knowledge or experience with refugees and torture survivors existed. The proper diagnosis and treatment of the mental health problems of refugees and civilian populations devastated by man- made and natural disasters were unknown.
In 1981, it was HPRT’s stated mission through scientific means to determine the impact of mass violence on people’s lives and to determine how to help survivors and their communities recover from catastrophic violence. The following scientific methods facilitated the achievement of HPRT’s mission.
HPRT’s approach has been steeped in the phenomenological traditions of Husserl and his followers.
Each generation wants to make its own discoveries without being blinded by the observations of the past. Consequently, HPRT, in order to confront the clinical phenomena of its refugee patients without prejudice, “”bracketed”” the phenomena. This phenomenological approach, which has been applied widely in Europe, allows the clinician to directly engage in experiencing the subjective experiences of his patients without introducing clinical biases that might obscure what actually exists.
HPRT applied this methodology of discovery to all of its clinical and empirical research activities. It has allowed HPRT to get as close to the clinical reality of the survivor as possible before being capture empirically by quantitative epidemiological studies.
The modern methods of psychiatric epidemiology were developed and defined in the 1970s and 1980s. While psychiatric epidemiology describes how mental disorder is distributed a population, it can also help reveal causes and indicate possible treatments. As Lee Robbins, a pioneer in American psychiatric epidemiology has stated, “”the epidemiologist tries to find out which portions of the population are at the greatest risk of becoming mentally ill, which recover quickly if they do become ill, and which are more likely to relapse after a temporary remission. By noting who is at high risk, the epidemiologist gets clues as to the possible causes of the occurrence of psychiatric disorder.”” [Archives of General Psychiatry, June 1978.]
Modern psychiatric epidemiology advanced its goals by developing survey instruments that could accurately measure psychiatric disease in the general population for the first time. A shift from studies of psychiatric patients to studies of mental illness in local communities also occurred, creating a revolution in understanding the frequency of specific types of mental illness as well as identifying those risk factors and resiliency factors associated with psychiatric disorders.
HPRT began with empirical clinical descriptions of its refugee patients, and then conducted large-scale community studies in refugee camps and post-conflict societies. In order to conduct its survey research, HPRT developed the first culturally validated screening instruments for measuring traumatic experiences and the symptoms of depression and posttraumatic stress disorder (PTSD). Culture-specific symptoms primarily related to functioning were also assessed. The Hopkins Symptom Checklist-25 was culturally adapted, along with the development of a new instrument, the Harvard Trauma Questionnaire (HTQ). The availability of valid and reliable instruments such as the HTQ that could be adapted to different refugee communities have led to numerous large scale studies that are describing for the first time the major psychiatric outcomes associated with mass violence, and the major risk factors associated with these outcomes.
Empirical methods have also been utilized by HPRT to assess the clinical care received by refugees and torture survivors in various settings. HPRT’s evaluation methods extend the survey approach used by Hollingshead and Redlich in the classic 1950s study, Social Class and Mental Illness. This method, which originated with the American sociologist, Kingsley Davis, in 1936, assumes that empirical scientific methods can unmask the treatment realities underlying the dogma and ideology that defends any treatment system. As Davis stated in his essay “”Mental Hygiene and the Class Structure””:
Mental hygiene hides its adherence behind a scientific façade, but the ethical premises reveal themselves on every hand, partly through a blindness to scientifically relevant facts….In so far as the mental hygienist retains his ethical system, he misses a complete scientific analysis of his subject and hence fails to use the best technological means to his applied-science goal. But if he forswears his ethical beliefs, he is alienated from the movement and suffers the strictures of an outraged society. Actually, the mental hygienist will continue to ignore the dilemma. He will continue to be unconscious of his basic preconceptions at the same time that he keeps on professing objective knowledge. He will regard his lack of preventive success as an accident, a lag, and not as an intrinsic destiny. All because his social function is not that of a scientist but that of a practicing moralist in a scientific, mobile world.
HPRT used this approach to conduct the first mental health survey of a refugee camp. Called “”Community of Confinement,”” this historic study of the mental health conditions of the famous Cambodian refugee camp known as Site 2 revealed the extraordinary trauma and mental health distress of camp residents that were almost completely denied or neglected by the UN and international humanitarian relief agencies running these camps. Similar research by HPRT and others in other refugee camps and asylum centers has revealed new insights into the mental health status of refugees, torture survivors and asylum seekers. Empirical scientifically based facts have had enormous influence on reversing international policies previously based upon myth and opinion.
Women’s Oral History Tradition
HPRT’s scientific methods have closely followed the directions mapped out by America’s greatest psychologist, William James, in his idea of “”radical empiricism.”” As a scientific method of discovery, James’ radical empiricism begins with the scientist becoming as close as possible to experiencing the pure psychological state or condition being studied. In other words, the scientist must hold his observing hand as close as he/she can to the phenomenological fire as long as possible without being burnt. This pre-theoretical state provides the necessary data for the hypotheses to be subsequently tested using more objective and standard empirical approaches and experiments.
A key Jamesian element in HPRT’s research methodology was the decade long collection of oral histories of Cambodian women by HPRT’s staff. HPRT’s oral history methods were derived from the Schlesinger Library’s focus on American women that believed that: (1) the history of women was not adequately represented in history books; (2) women made significant contributions to history; and (3) women’s oral histories were readily available and provided unique opportunities to address (1) and (2), especially with living women. An additional dimension that influenced HPRT’s oral history approach was that ordinary women were significant interpreters and participants in history. This meant a shift away from only interviewing famous women or the intellectual elite.
HPRT, inspired by the women’s oral history Schlesinger Library model, elected to interview Cambodian women who were newly arrived in the United States. Cambodian women were chosen who represented different social classes, (e.g., rice farmer), privileged positions (e.g. princess) and professional status (e.g. classical dancer.) This was the first oral history project at the Schlesinger Library to focus on “”ordinary”” immigrant women who had resettled in America.
New methodologies can produce new insights and knowledge. In this case, these oral histories have revealed a phenomenological architecture to the “”trauma story”” that is being used to train clinicians throughout the world.