The Long-Term Mental Health Consequences of Torture, Loss, and Insecurity: A Qualitative Study Among Survivors of Armed Conflict in the Dang District of Nepal.

Hanna Kienzler,Ram P Sapkota

doi:10.3389/fpsyt.2019.00941

Abstract

Background and Objectives: Nepal has witnessed several periods of organized violence since its beginnings as a sovereign nation. Most recently, during the decade-long Maoist Conflict (1996–2006), armed forces used excessive violence, including torture, resulting in deaths and disappearances. Moreover, there is widespread gender-, ethnic- and caste-based discrimination, and grossly unequal distribution of wealth in the country. While the immediate mental health effects of the conflict are well studied, less is known about the long-term effects of the conflict. This article sets out to explain how Nepalese survivors of violence perceive their wellbeing and mental health, search for help and construct their health care pathways and therapeutic itineraries. The aim is to provide a better understanding of local explanatory models and healthcare behaviors. Methods: Semi-structured interviews were carried out with 25 people (14 men, 11 women) aged 30 to 65 in Dang district in 2013. To elicit illness narratives, a translated and culturally adapted version of the McGill Illness Narrative Interview (MINI) was used. Additionally, participants were interviewed about their war experiences and present-day economic and social situations. The transcripts were coded using deductive and inductive approaches and analyzed through thematic analysis. Results: The study provides insight into temporal narratives of illness experience and explanatory modules. Symptoms were found to be widespread and varied, and were not solely attributed to violent experiences and memories, but also to everyday stressors related to survivors’ economic, social, and familial situations. In terms of help- and health-seeking behavior it was found that participants resorted to various coping strategies such as social activities, avoidance, withdrawal, and substance use. Many participants had received biomedical treatment for their psychosocial problems from doctors and specialists working in public and private sector clinics and hospitals as well as different forms of traditional healing. Conclusions: These results shed light on the long-term impact of the Nepalese conflict on survivors of extreme violence, highlighting local explanatory models and help- and health-seeking behaviors. These findings inspire recommendations for the development of context specific and holistic psychosocial interventions focusing on well-being, social determinants of health, and human rights.

Highlights

Nepal, never colonized by any other country, has witnessed structural and organized violence since its unification as a sovereign nation in the mid-eighteenth century including, most recently, during the decade-long Maoist Conflict (1996–2006) [1]
Support for survivors is usually provided on a short-term basis in the form of humanitarian assistance, which increasingly includes the provision of psychiatric and psychosocial services to address trauma-related mental health problems [4,5,6,7,8]
The results presented in this article form part of the qualitative component of the research project which was complementary and explored the ways in which people suffering from traumarelated health problems as well as ongoing socioeconomic stressors perceive their mental health problems, seek help and construct their health care pathways and therapeutic itineraries

Summary

Introduction

Never colonized by any other country, has witnessed structural and organized violence since its unification as a sovereign nation in the mid-eighteenth century including, most recently, during the decade-long Maoist Conflict (1996–2006) [1]. During the Maoist Conflict, armed forces used excessive violence, including torture, resulting in deaths and disappearances. While the immediate mental health effects of the conflict are well studied, this article provides insight into the ways Nepalese survivors perceive their mental health problems, seek help, and respond to mental health treatment in the long-term. Understanding the long-term effects of armed conflict on people’s mental health and wellbeing is crucial for several reasons. Most recently, during the decade-long Maoist Conflict (1996–2006), armed forces used excessive violence, including torture, resulting in deaths and disappearances. According to the human development index (HDI) report, Nepal is among the medium development countries with an HDI ranking of 149 out of 189 countries with a per capita income of US $1004, life expectancy of 70.6 years and adult literacy rate of 59.6% [20, 21]

Results

Discussion

Conclusion