Self-help or silenced voices? An ethnographically informed warning – Authors' reply
Authors: Wietse A Tol, Marx R Leku, Kenneth Carswell, Mark van Ommeren
Journal: The Lancet Global Health (2020)

We thank Costanza Torre for her observations. In our Article,1Tol WA Leku MR Lakin DP et al.Guided self-help to reduce psychological distress in South Sudanese female refugees in Uganda: a cluster randomised trial.Lancet Glob Health. 2020; 8: e254-e263Summary Full Text Full Text PDF PubMed Scopus (86) Google Scholar we described the results of a facilitated, group-based, guided self-help intervention to reduce psychological distress among female South Sudanese refugees in Rhino Camp settlement, northern Uganda. Torre's response is based on ethnographic doctoral fieldwork in a different refugee settlement in northern Uganda. Although we appreciate her insights, we think that some of her comments might be premature. Torre argues that the psychosocial intervention we evaluated might have reduced participants' opportunities to voice ongoing concerns and needs in the refugee settlements, because it largely concerns a one-way intervention. This argument glosses over the fact that the guided self-help intervention is group-based, that its contents promote strengthening social support and community engagement (as outlined in the paper's appendix pp 2–3), and that there are direct opportunities for interactively voicing concerns, prioritising personally experienced stressors, and identifying ways to best manage these stressors, including in small, group-based exercises with other participants. In addition, the argument ignores the fact that facilitators are trained to support participants who request additional support through conversations that encourage linking to existing community supports (eg, village leaders and other supportive groups within the community). Her argument seems to hinge at least partly on the presumption that psychological distress is not also one of the refugees' “very real” concerns. Our own qualitative research and programmatic engagement in the settlements since 2012 has shown that “overthinking” is highlighted by refugees as a key concern,2Adaku A Okello J Lowry B et al.Mental health and psychosocial support for South Sudanese refugees in northern Uganda: a needs and resource assessment.Confl Health. 2016; 10: 18Crossref PubMed Scopus (24) Google Scholar as it is for many populations facing structural adversities.3Kaiser BN Haroz EE Kohrt BA Bolton PA Bass JK Hinton DE “Thinking too much”: a systematic review of a common idiom of distress.Soc Sci Med. 2015; 147: 170-183Crossref PubMed Scopus (137) Google Scholar, 4Tol WA Ebrecht B Aiyo R et al.Maternal mental health priorities, help-seeking behaviors, and resources in post-conflict settings: a qualitative study in eastern Uganda.BMC Psychiatry. 2018; 18: 39Crossref PubMed Scopus (16) Google Scholar In addition, psychological distress and other ongoing stressors faced by refugees (eg, those listed by Torre, such as poverty, gender-based violence, and physical health concerns) are intricately related in complex, bidirectional relationships.5Lund C Brooke-Sumner C Baingana F et al.Social determinants of mental disorders and the Sustainable Development Goals: a systematic review of reviews.Lancet Psychiatry. 2018; 5: 357-369Summary Full Text Full Text PDF PubMed Scopus (316) Google Scholar, 6Silove D Rees S Tay AK et al.Pathways to perinatal depressive symptoms after mass conflict in Timor-Leste: a modelling analysis using cross-sectional data.Lancet Psychiatry. 2015; 2: 161-167Summary Full Text Full Text PDF PubMed Scopus (15) Google Scholar Effective interventions that reduce psychological distress could therefore be critical elements of efforts to address these stressors. In addition, Torre warns that stand-alone psychosocial interventions might be perceived by refugees as humanitarian agencies' disengagement from other concerns that they face. In our trial, we integrated the intervention within a robust referral system for mental health concerns, but did not evaluate the intervention in combination with a range of other humanitarian programming. This design was selected to first understand the psychological impacts of this newly developed intervention. As noted in our manuscript, now that our evaluation has shown promising benefits, we think it is critical to understand how interventions that can effectively reduce psychological distress can be integrated with other humanitarian support, including areas such as gender-based violence and livelihoods programming. The implementing partner, HealthRight International, is actively using such integrated support. Compared with other existing evidence-based interventions, the scalable format of this guided self-help intervention has the potential to greatly increase the feasibility of such integration. We declare no competing interests. Guided self-help to reduce psychological distress in South Sudanese female refugees in Uganda: a cluster randomised trialSelf-Help Plus is an innovative, facilitator-guided, group-based self-help intervention that can be rapidly deployed to large numbers of participants, and resulted in meaningful reductions in psychological distress at 3 months among South Sudanese female refugees. Full-Text PDF Open AccessSelf-help or silenced voices? An ethnographically informed warningWietse Tol and colleagues' study1 in The Lancet Global Health describes the benefits of Self-Help Plus, a transdiagnostic psychological intervention aimed at stress reduction in humanitarian settings. Based on a randomised controlled trial in a refugee settlement in northern Uganda, their findings are impressive and benefit from extensive research. However, my ongoing, in-depth ethnographic research during the past 12 months in Palabek refugee settlement, northern Uganda, has identified crucial aspects that the study overlooks. Full-Text PDF Open Access