Assessment of the psychosocial and mental health needs, dysfunction and coping mechanisms of violence affected populations in Bireuen Aceh. A qualitative study

Abstract

Qualitative research is important due to the shortage of literature in understanding cultural influences on psychosocial and mental health syndromes and their presentation, especially in developing countries. This qualitative study aims to investigate the psychosocial and mental health needs of populations in Aceh, Indonesia affected by over 30 years of conflict, their dysfunction, and their positive coping mechanisms. Results from this qualitative assessment indicate the presence of depression, anxiety and somatic symptoms. The data provide local terminology and ways in which the local population describes their own distress, which is an important addition to the understanding of the mental health consequences of this conflict. The data has been used to develop appropriate intervention strategies and adapt and validate assessment tools to measure psychological distress, dysfunction and coping mechanisms.

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218
Abstract
Qualitative research is important due to the
shortage of literature in understanding cultural
influences on psychosocial and mental health
syndromes and their presentation, especially in
developing countries. This qualitative study aims
to investigate the psychosocial and mental health
needs of populations in Aceh, Indonesia affected
by over 30 years of conflict, their dysfunction, and
their positive coping mechanisms. Results from
this qualitative assessment indicate the presence
of depression, anxiety and somatic symptoms.
The data provide local ter minology and ways in
which the local population describes their own
distress, which is an important addition to the un-
derstanding of the mental health consequences of
this conflict. The data has been used to develop
appropriate intervention strategies and adapt and
validate assessment tools to measure psychological
distress, dysfunction and coping mechanisms.
Keywords: violence, qualitative, psychosocial, dys-
function, coping
Introduction
The problems and needs of survivors of
violence in Aceh, Indonesia are closely con-
nected with the conflict between The Free
Aceh Movement (GAM) and the Indonesian
Government that went on for over 30 years.
As GAM struggled for independence and
the Indonesian government tried to curb
it through military operations, the people
of Aceh experienced and witnessed signifi-
cant violence. During the Suharto regime
(1967 to 1998), the people of Aceh faced a
lot of violence, and were hopeful after the
fall of Suharto in 1998 that they would see
peace. Unfortunately, the conflict continued,
and in 2003, Aceh was put under martial
law following the failure of the Cessation
of Hostility Agreement (CoHA) that was
signed on Dec 9, 2002 by the GAM and the
government of Indonesia. This continued
the conflict until the devastating tsunami in
December 2005. After the tsunami, both the
GAM and the Government of Indonesia es-
tablished a truce, with peace finally realized
Assessment of the psychosocial
and mental health needs, dysfunction
and coping mechanisms of violence
affected populations in Bireuen, Aceh
A qualitative study
Bhava Poudyal, MA*, Judith Bass**, Theodora Subyantoro, MA*,
Abraham Jonathan, BA*, Theresia Erni, LLB*, & Paul Bolton, MBBS***
*) International Catholic Migration Commission (ICMC)
Jakarta
Indonesia
poudyal@icmc.net
**) Department of Mental Health
Johns Hopkins Bloomberg School of Public Health
Maryland
USA
jbass@jhsph.edu
***) Center for Refugee and Disaster Response
Johns Hopkins Bloomberg School of Public Health
Maryland
USA

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219
in September 2006 when GAM was allowed
to be a political party and participate in elec-
tions and local and national government.
A study conducted around this time by
the International Organization for Migra-
tion1, 2 in high-conflict communities across
Aceh found that nearly three-quarters of
those assessed reported living through com-
bat, with more than one-quarter reporting
having been beaten and nearly forty percent
reporting a family member or friend being
killed. With this exposure to violence, they
also found high rates of depression symp-
tomatology, post-traumatic stress disorder
and anxiety.
While this study indicates high rates of
mental health problems among the general
population, it does not provide us with suf-
ficient information to develop targeted inter-
ventions and locally useful assessment tools.
To get the necessary information, we used
qualitative methods to explore important
mental health problems, dysfunction and
coping strategies from a local perspective.
Data from this type of assessment consist
of how local people view their problems in
terms of the nature of these problems, their
severity, their causes, and how people deal
with them. Program implementers can use
this information to select problems that
match local priorities, and to design and
adapt interventions that are likely to be ef-
fective in terms of local feasibility and co-
operation. The information is also useful in
designing indicators and assessment tools to
evaluate both the need for, and the impact
of, programs and to monitor their imple-
mentation.3, 4 In this report we present the
results from our qualitative study that iden-
tifies targets for intervention including the
salient mental health problems, indicators of
functional impairment, and coping strategies
that could be enhanced.
In the context of this qualitative study,
“violence” refers to all acts of intentionally
inflicted physical and/or psychological injury,
whether by a person acting on their own
initiative or under the direction of another
person, and excludes accidental injury. The
term “survivors of violence” includes not
only those who were injured but also others
who have been affected by these acts either
by indirect exposure (such as witnessing an
act) or by having to live with their conse-
quences (such as family members).
Study purpose
The primary purpose of this qualitative
assessment was to understand how local
people affected by violence perceive their
current psychosocial and mental health
problems resulting from these experiences,
including the variety, importance and sever-
ity of these problems, the nature and ter-
minology used to describe these problems,
their perceived causes, and what people do
to help themselves when they have these
problems. In addition, data were gathered
to identify what constitutes the most im-
portant aspects of normal daily functioning
in order to design locally-appropriate meas-
ures of functional impairment. Finally, data
were also collected to understand the various
coping skills used by the local population to
minimize their excessive negative emotions
and to deal with daily life stress.
Study location
The interviews for this qualitative study
were conducted in three villages in Bireuen
district, one of the hardest hit districts in
Aceh.1 These three villages were representa-
tive of the region in terms of nature and
severity of conflict experiences, social eco-
nomic status, and size of the villages. All the
interviews were conducted in these three
villages at people’s homes, under trees, or at
local mosques.

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Methodology
This study draws on methods developed by
Bolton and colleagues,5, 6 that have been
applied in other under-resourced and fra-
gile environments. Local interviewers were
trained in the use of open-ended, non-lead-
ing methods of interviewing in which the
respondent is probed for as much informa-
tion on a topic as they know and are willing
to say. Everything the respondent says is
recorded verbatim, without summarization,
paraphrasing or translation. Respondents
were chosen to represent the diversity of the
population and for their particular know-
ledge of the issue being assessed.
The study involved two weeks of train-
ing, data collection and analysis. Twelve
interviewers, who were native Acehnese
language speakers, received training and
daily supervision throughout the interview
process. Interviewing was done by means of
three qualitative methods used sequentially:
Free listing, key informant interviews, and
focus groups, with all interviewers working
in pairs.
Free listing interviews
Seventy-one community members (36 male,
35 female) were interviewed using this first
technique. Respondents included those ex-
posed directly to the violence and members
of their families, as well as locally respected
persons (community leaders and well known
local people). Respondents were asked the
primary question: “What are some of the
problems that people affected by violence in
your community face?” Interviewers probed
each respondent for as many problems as
the respondent could think of. For each
problem, interviewers recorded its name and
a short description, in the exact words of the
respondent in their local language.
At the end of the interview, interviewers
reviewed the list for potential mental health
or psychosocial problems, defined as prob-
lems referring to thinking, feeling or relation-
ships. For each of these problems, they asked
the respondent for the names and contact
information of local people who are knowl-
edgeable about that problem and/or who
people with these problems go to for help.
The focus was on identifying key informants
who come from the local area (in contrast
to professionals such as health care or social
workers who work in areas but often come
from elsewhere). This contact information,
and the problem each “expert” was said to
be knowledgeable about, was recorded sepa-
rately from the interview.
To analyze the free lists, the interview-
ers condensed all of their lists into a single
composite list of all the psychosocial and
mental health problems. Two problems (fear
and too many thoughts) were selected for
further investigation with the key informants
(described below) in that they appeared fre-
quently, were interpreted by the interview-
ers to relate to many of the other problems
mentioned, and the project implementers
thought they would be able to address those
two problems with their counseling program.
Four additional free lists were generated
from each respondent, gathering informa-
tion about the important day-to-day activ-
ities and tasks that men and women do to
care for themselves, their families, and their
communities, and on the coping strategies
they use to deal with their problems. This
information was sought with the intention of
formulating locally appropriate indicators of
functioning and coping.
Key informant interviews
A total of 22 key informants (KI) were inter-
viewed using the second interviewing tech-
nique. The KIs were identified through the
names and contact information provided by
the free list respondents described above and

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by “snowball sampling” (i.e. referral by one
key informant of another key informant). In
addition, some of the free list respondents
who were identified as clearly knowledgeable
were enlisted as key informants. Fourteen
(64%) of the KIs were interviewed between
2 to 4 times in order to record as much
information from them as possible. Five of
the KIs were only interviewed once because
upon review of their responses they were
deemed to either be unknowledgeable about
the problems and/or the population of inter-
est.
Key informants were asked to tell all
they knew about each of the two problems
fear and thinking too much, with particular
reference to the nature of each problem, its
causes, effects, what people do to address
each problem, and what could be done by
others to help. Like with the free list inter-
views, the study interviewers conducted the
analysis of the KI interviews. The interview-
ers reviewed the text of the interviews to
identify all the different signs and symptoms
mentioned for each problem area, indicating
how many different KIs reported each sign
and symptom. Items that the interviewers
identified as meaning the same thing (i.e.
don’t want to talk and quiet) were grouped
together. For signs and symptoms that were
grouped together as meaning the same
thing, the interviewers were asked to come
to a consensus as to one of the terms that
could be used to capture the overall meaning
of the group of terms. The end product were
two lists, one each for fear and thinking too
much, with all the different signs and symp-
toms and the frequency with which each was
reported.
In addition to the analysis of the signs
and symptoms, the interviewers also re-
viewed the KI interviews to identify local
ways that people coped with the problems
they had.
Focus groups
To further explore functioning among
the local population, one focus group was
convened. During the focus group, the par-
ticipants were provided with a summary of
the results of the task lists from the earlier
free list interviews. The participants, con-
sisting of 5 male and 5 female KIs, were
asked to confirm if these were the activities
and tasks that men and women regularly
do across all three domains (care of self,
family, community) and if there were other
important activities not listed. To complete
the discussion, the group was asked to
identify the most import ant tasks for each
gender, understanding that all of the identi-
fied tasks were activities that both men and
women do regularly.
Results
This qualitative assessment was completed
in two weeks in September 2006. Table 1
presents the mental health problems men-
tioned by at least 10% of the free list sample
(n=71). The problem of fear was the most
mentioned problem (44 respondents) fol-
lowed by heart pounding, heavy heart, shak-
ing and trembling and thinking too much.
Reviewing the results, the interviewers
thought that the problems of heart pound-
ing, shaking and trembling were all encom-
passed within the problem of fear, with fear
being the emotion and the other three being
the symptoms that accompany fear, which
is consistent to the cluster of symptoms of
anxiety in the Western model. Heavy heart
was encompassed within thinking too much
by the interviewers, and the study team also
thought this might be the theme for Depres-
sion from the Western model. Therefore, the
in-depth key informant interviews focused
on the primary problems of fear and think-
ing too much.
For the analysis of the KI data separate

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lists were generated for each problem: fear
and thinking too much (Table 2). Review
of the KI interviews indicated significant
overlap and that each primary problem often
showed up as a symptom within the descrip-
tion of the other problem. The overlap in
symptoms can be seen clearly except for
“isolation” which is only seen for the prob-
lem of “thinking too much”.
Table 3 provides information on what
the KIs indicated that the survivors of vio-
lence and their families do to help them-
selves when they experience distress. The
identified strategies ranged from things the
individual does by him/herself (i.e. go for a
walk) to things he or she does with others
(i.e. have discussions with friends or family).
We did not ask the KIs to identify which of
the coping strategies they considered “posi-
tive” or “negative.” Thus, the strategies need
to be evaluated by program staff for what
they would consider to be coping strategies
that could be promoted, or leveraged, in an
intervention strategy.
Table 4 presents a summary of the daily
tasks and functions, separated by gender,
generated from the free lists and identified
as important in the focus group discussion.
These items will be used to develop an as-
sessment of functional impairment that
would measure an individual’s inability to
carry out the specified tasks and activities.
Discussion
For assessment of mental health and psy-
chosocial problems in non-Western envir-
onments, it is typical for programs and
researchers to translate standard Western
assessment tools and conduct screening.2
Field practitioners often express concerns
over such methodology. The author’s own
experience (BP) includes a situation when
survivors of torture and violence answered
that they always have recurrent memories of
the traumatic event when screened through
a translated Harvard Trauma Question-
naire,7 but on further probing, the recurrent
memories were actually of loss of cattle and
property, and not the recurrent memory of
Table 1. Mental health and psychosocial problems
identified from the free listing interviews (71 re-
spondents).*
Problem Description Frequency
Fear/afraid . . . . . . . . . . . . . . . . . . . . . 44
Heart pounding . . . . . . . . . . . . . . . . . 31
Heartache/Heavy heart . . . . . . . . . . . . 15
Shaking, trembling . . . . . . . . . . . . . . . 14
Too many thoughts/ thinking too much 12
Body pain/stiffness . . . . . . . . . . . . . . . 10
Anger/feelings of revenge/resentful. . . 9
Worried, anxious, stressed . . . . . . . . . 8
Chest pain (broken chest) . . . . . . . . . . 8
Sad . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Trauma . . . . . . . . . . . . . . . . . . . . . . . . 8
Remember the loss . . . . . . . . . . . . . . . 7
*) Problems mentioned by 10% or more of the
respondents are presented.
Table 2. Signs and symptoms of “fear” and “think-
ing too much” from the KI interviews (22 respond-
ents)*
Frequency Frequency
“thinking
Symptoms
too much”
“fear”
Body is sick/body pain 12 11
Weak body/no energy 12 10
Heart pounding 5 15
Not calm/can’t sit still/
restless 8
Spacing out 15 4
Loss appetite/forget to eat 8 4
Easily get angry 9 3
Can’t sleep/sleep difficulties 6 5
Shaking 1 10
Unhappy/sad 8 2
Broken hearted/heavy heart 2 7
Isolation 7 0
Quiet 4 3
Fever/body feel cold/body
feel hot 2 6
Remembering the loss 2 6
Feels like everything done is
wrong (guilt) 3 1
*) Symptoms mentioned by two or more of the KIs
are presented.

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Done by self Done with others
Pray Recite Koran with others
Work Discussions with family/friends
Find recreation Kenduri (cook for others during ceremonies)
Sit at home not going anywhere Play football and volley ball
Do more fasting (religious) Listen to lectures by religious leader
Go to look for money Avoid fights and arguments with others
Go for a walk Get involved in community work
Vow (make promises to God about making amends if he granted the wish)
Table 4. Female and Male Task and Activity List.
Female tasks and activities Male tasks and activities
Take shower Earn money
Put on make up Eat rice
Iron clothes Pray
Eat rice, meals Sport (volleyball, football)
Sit around for relaxation, chat with others Take a bath
Pray Help clean up the house/fixing the house
Cook Go to the market to shop (buy rice, fish)
Prepare the children to go to school Shave
Wash clothes Religious art (recite traditional poetry in
Arabic language)
Work Recite Koran
Take care of self (wear clothes, comb hair,
take a nap, cutting nails) Community work
Wash dishes Community meeting
Fetch water Go to kenduri (ritual/ceremony meals)
Look for woods Music art (related with prayer and religion)
Educate children Brush teeth
Kenduri/cooking for people having
ceremony or ritual Brush hair
Clean up the house Visit people who experience calamity
Take care of children
Earn money
Take care of elderly
Participate in Family Welfare Program
(making cakes, sewing traditional fan)
Learn/recite Koran regularly
Community work (clean up mosque)
Visit people who experience calamity
Table 3. Coping strate-
gies identified during the
Key Informant interviews
(22 respondents).

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the torture or violence they experienced, as
purported by the question. Another example
is the issue of asking about nightmares. Our
experience is that people respond positively
to the question on nightmare when they
might have a dream that culturally signifies
bad luck (i.e., dreaming of your tooth falling
out). When further probed, they might not
be distressed by the dream, but are worry-
ing constantly about other things, like how
to send their child to school. This raises the
challenge of the assessment tool’s validity in
the local context, which cannot be assessed
without understanding the local language,
expressions of distress and what is consid-
ered problematic.
These challenges emphasize the import-
ance of understanding what is distressing to
the targeted population first.8 Understanding
local idioms of distress is a valuable way to
gain a more in-depth understanding of local
mental health symptomatology. For example,
in this study conducted all in Acehnese, we
identified several expressions of distress like
“Ule Mekerlep”, which literally translated
means ‘cockroaches running around in your
head’ and “Jantoeng ie meu en”, which liter-
ally translated as “heart is playing.” When
the Acehnese interviewers were asked to de-
scribe what these idioms meant, the former
was described as meaning having “too many
thoughts” and the latter as being restless.
Beyond just generating local idioms of
distress, the study also gathered signs and
symptoms that define the mental health
problems experienced by the local popula-
tion. The study results showed a lot of gen-
eral psychological symptomatology but did
not generate any evidence that these prob-
lems are grouped together within individuals
as a specific syndrome or set of syndromes.
The study team was open to finding symp-
tomatology of Post Traumatic Stress Dis-
order (PTSD) or Major Depressive Disor-
ders as might be expected from the literature
on post-conflict populations.9, 10 However, if
we use the Western clinical model, then co-
morbidity of anxiety and depression symp-
toms, together with somatic presentations of
distress, appears to be the most appropriate
way to define the mental health problems
faced by this population. This finding is also
consistent with published literaturewhere
anxiety and depression are the most com-
mon mental health problems with people
exposed to extreme stressors.11 Besides the
mental health problems, economic problems
and general health problems also stood out
as an important problem in the community.
Promoting positive coping mechanisms
for people exposed to extreme stressors is
a recommended intervention strategy.12 It
is assumed that all populations have their
own ways to deal with distress, informed
by cultural, economic, and environmental
influences. The study team investigated the
coping mechanisms of the targeted popula-
tion to understand what people do to cope
to reduce their levels of distress in their con-
text. Among the strategies that were impor-
tant to this population included a variety of
religious practices (praying, reciting Koran,
fasting, making vows) as well as activities
that promote interaction with others (play-
ing sports, community work). Identifying
what the local population already does, both
positive and negative strategies, is important
for ensuring interventions fit within the local
context and build upon strategies that are
already used locally.
In recent years, the focus of research-
ers and field practitioners has shifted be-
yond only focusing on symptomatology
to including assessing dysfunction as well.
Standard tools, like the WHO-DAS II13 ex-
ist. However, upon exploration with the
local experts, it was found that some items
like “standing for long periods of time” and

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225
“walking a long distance” were vague and
very subjective, depending on the local con-
text. Additionally the tool does not address
the different roles and tasks of men and
women within the local context. With the as-
sumption that local tasks and roles may vary
from culture to culture, the research team
relied on local people to identify the import-
ant specific tasks that an adult man and
woman needs to do to care for themselves,
their family, and participate in their com-
munity. Using this locally specific informa-
tion allowed us to develop tools to measure
functioning that get at the important things
local people need to do, rather than a more
general measure of impairment.
This study explored the psychosocial
and mental health symptoms and problems,
indicators of functioning, and coping strat-
egies and did not investigate the domains
of economic problems and general health
problems that were also mentioned as major
problems by the community. Understand-
ing how the economic situation and general
health issues impact mental health and how
mental health problems impact economic
and general health issues is an important is-
sue for future research.
Conclusions
Based on the study results the community
perceived psychosocial and mental health
problems as major problems, along with
general health and economic problems. The
psychosocial and mental health problems for
this population fell within the domains of
anxiety and depression problems combined
with somatic presentations of distress. These
general results are similar to those found in
a psychosocial needs study conducted by
International Organization for Migration,1
yet this study adds the local description and
expression of these problems rather than
relying on the Western models defined by
the standard instruments used in the IOM
study. In addition to symptomatology, this
study also adds the dimensions of function-
ality, and local coping mechanisms.
The importance given to the mental
health problems identified by people in the
community led the researchers to develop a
community-based psychosocial counseling
program that was implemented by locally
based NGO staff trained and supervised by
ICMC. The local idioms of distress and the
important signs and symptoms were used to
adapt standard Western tools, making them
more appropriate to the local population
than basic translation methods would have
done. These assessment tools were then used
to screen people into the psychosocial pro-
gram and evaluate its impact. The validated
mental health assessment tools and measures
of dysfunction and coping are available from
authors by request.
Acknowledgements: Special thanks go to several
people for making this assessment possible.
Thanks to Melinda Hutapea, for the amazing ad-
ministrative and logistical support she provided.
Thanks to the RATA staff and the interviewers
who worked tirelessly not only as interviewers but
who also assisted with any and all issues that came
up throughout the study. Finally, thanks to the
Victims of Torture Fund at USAID/DC for their
continuing support and encouragement of this
project.
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