The APS Grant for Intercultural and/or International Projects supports innovative projects that have an intercultural and/or international focus, particularly in countries where psychology is an emerging discipline. The 2014-15 Grant was awarded to Zoe Collins MAPS, Clinical Psychologist, on behalf of the commit and act team. The project’s aim was to decrease mortality and infection from the Ebola virus in Sierra Leone, by working to increase coping strategies among affected communities using evidence-based psychological techniques to empower and mobilise communities at risk.
How did you come to be involved with the project in Sierra Leone? What was your role?
I have always had a keen interest in working in cross-cultural psychology and global mental health. I was interested in how Global Mental Health NGOs could apply therapeutic strategies to assist people in need. My role with commit and act included participating in their 2014 trip to a clinic in Bo, Sierra Leone where I was involved in the coordination of Acceptance and Commitment Therapy (ACT) trainer workshops and research as well as assisting with the opening of the clinic. Back in Australia I helped coordinate their grant-writing and research projects as well as web coordination.
Can you explain how a psychotherapeutic approach like Acceptance and Commitment Therapy (ACT) can be applied to a public health pandemic like Ebola?
Sierra Leone had almost no previous history of Ebola before the world’s worst epidemic of the virus in 2014. Several factors significantly contributed to its spread, including: lack of health education, minimal knowledge about Ebola, stigma of being infected with the virus, fear of death from the disease, associating health workers and hospitals with death, and clashes between important cultural practices and effective Ebola prevention strategies. Cultural obstacles that increased infection rates included traditions about washing dead family members, caring for sick families, and eating bush meat.
The dilemma at hand was that it was still paramount for the Leonean people to maintain their traditional practices, such as washing their dead loved ones and keeping them in their house until burial. Understandably, people were frightened that violating these customs would bring shame and a ‘curse’ upon their family.
ACT and the related ‘Prosocial’ group psychology principles focussed on helping to strengthen Leonean community dynamics and improve their decision-making in line with optimal Ebola health promotion. ACT interventions aimed to increase psychological flexibility, helping people move past these multiple health-impacting obstacles and achieve their valued goals for the health of their communities in this time of crisis.
A key strength of the ACT Prosocial approach lies in teaching people to accept their predicament, thereby helping them and their families in effective behavioural change. There could only be improvement in infection rates when communities (and their leaders) adopted appropriate preventive behaviours that were in line with and motivated by their core values, rather than these values being experienced as an immovable obstacle. The Prosocial group strategies facilitated the creation of a social environment which favoured cooperation and guarded against behaviours that could undermine group goals, such as fear of stigma for not carrying out cultural practices.
How did the APS Grant for International and/or Intercultural Projects assist the work of the commit and act team?
The APS Grant significantly contributed to commit and act's innovative psychotherapeutic health promotion work. With the APS funding we conducted multiple Prosocial Ebola trainings for psychosocial assistants to conduct health promotion workshops and disseminate key Ebola health information to Leonean communities, directly reaching an impressive 6000 people.
These community workshops included ACT information dissemination about:
- The cultural practices that were conflicting with optimal health,
- Encouraging communities to self-govern Ebola prevention strategies, and
- Promoting Prosocial Ebola training.
The target groups we reached for psychological support and counselling were:
- Ebola-infected individuals, families and communities, including children and orphans,
- Suspected Ebola-infected victims,
- Families of Ebola survivors,
- Frontline workers (including medical staff, burial teams and cleaners), and
- Families and communities in denial of the Ebola epidemic.
Materials provided included:
- Alternative burial ceremony equipment,
- Hygiene material, and
- Print and radio media health promotion.
What are some immediate or potential applications of your efforts to apply ACT strategies within the cultural context of Sierra Leone? Has anything emerged that you didn’t expect?
commit and act has been excited about Sierra Leone’s appreciation and cultural applications of ACT. Our psychological trainings in the country for the last seven years have validated ACT as an effective therapy for Leonean adaptation. We were surprised at the flexibility local communities showed in embracing the application of Prosocial and ACT strategies to overcoming Ebola stigma and modifying traditional practices to focus on community values of health promotion. “This is psychological flexibility and values-based living in action,” wrote ACT co-founder Steven C Hayes in an article in the Huffington Post, “Kissing The Banana Trunk: Will You commit and act in the Fight Against Ebola?”
Hayes’ (2014) article explains how it is customary in much of West Africa to keep the bodies of dead relatives in the home for several days – “praying over them, washing them, dressing them, even hugging and kissing them”. People who don't do these ceremonies believe they have dishonored their relatives, and may even be rejected by their community.
With burial customs such an important and established part of cultural practices, efforts to change them can meet with resistance. The commit and act team aimed to target these practices not by forcing people to burn the infected bodies, but by helping them to come up with alternative burial customs that accorded with their values but still allowed health workers to dispose of bodies with minimal infection contamination. This psychological flexibility was created by taking groups of people through ACT and Prosocial education programs led by community members themselves, beginning with the message that Ebola was real and must be taken seriously (the 'acceptance' stage).
Hayes gives an example of this flexibility from one community that substituted the infected corpses with a banana trunk. Instead of the corpse, relatives keep a banana trunk at home and perform all of the customary rituals on it, including kissing the banana trunk before burial. In the end, the banana trunk is buried while the body of the infected and deceased person is burned.
In what ways has your collaboration with commit and act evolved, and how might it advance the discipline of psychology and the profile of the APS internationally?
Mental health concerns are increasing globally, but are often neglected due to minimal resources in lower-middle income countries. With the $10,000 we were able to train several groups of psychosocial workers and teachers to disseminate ACT-informed Ebola health promotion to 6000 people. These efforts have been greatly appreciated and the regions commit and act trainers targeted were found by local government statistics to have had larger declines in new rates of infection.
Involvement of psychologists globally can promote awareness of the many uses of psychological techniques. Using psychological techniques to increase the coping strategies of affected and at-risk communities is in line with the APS mission statement, and is particularly important in a country with no psychology training.
What kinds of personal qualities and professional skills have been most valuable to you in this project?
Volunteering with a grassroots cross-cultural not-for-profit means psychological flexibility is imperative! Patience, commitment, and an ability to reach out empathically despite timezones and other commitments are all important qualities. Working on a multicultural Board and with locals from Sierra Leone requires cultural sensitivity, and an openness to learn is key in understanding other people’s decisions and, specifically in our case, how ACT can be adapted to Leonean culture.
Is there a take-home message for us as psychologists here in Australia, and as global citizens?
As Australian psychologists we are equipped to influence a healthier and fairer societal future. As therapists and researchers we are in a unique position to advocate for and participate in global mental health initiatives that bring together our expert knowledge and evidence-based techniques with commonly held values of social justice, compassion and equality. As a society, we are more globally connected than ever – across timezones, borders and economic divides. Along with the Board of commit and act , I encourage psychologists to get involved in global mental health.
Thanks to Heather Gridley for arranging this interview.