November 10, 2023 • 37 mins
Strengthening Mental Health in Conflict Zones: A Conversation with Dr. Nawaraj Upadhaya
In this episode of the Conflict Tipping Podcast, host Laura May interviews Dr. Nawaraj Upadhaya, Global Mental Health Director at HealthRight International. Dr. Upadhaya shares about his experience developing and implementing a WHO-associated Self-Help Plus intervention in Uganda and Sudan, targeting individuals dealing with mild to moderate stress. The intervention uses techniques based on Acceptance and Commitment Therapy and mindfulness and is delivered by lay health workers who need only a week's training. Dr. Upadhaya further elaborates on the intersection of mental health and conflict, the ethical dilemmas faced when working in conflict zones, and the need to care for frontline workers. He discusses how his personal background and experiences inform his work. Dr. Upadhaya's approach aims to empower individuals in difficult situations to find resilience and make positive changes in their lives.
00:00 Introduction and Guest Presentation 01:16 Understanding the Self-Help Plus Intervention 04:29 The Impact of the Intervention on Participants 07:25 The Power of Resilience in Conflict Zones 08:25 The Process of Implementing the Intervention 14:22 The Future of the Intervention 28:52 The Role of Mental Health in Conflict 31:57 Ethical Considerations in Conflict Work 34:17 Caring for the Carers: Staff Wellbeing 35:27 Conclusion and Contact Information
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Dr Nawaraj Upadhaya, PhD, is a public health researcher and mental health system specialist. He is currently working as Global Mental Health Director at HealthRight International, New York, USA where he provides strategic and technical support in mental health and psychosocial support programming. Dr Upadhaya is also associated with the Department of Public Health, University of Copenhagen, Denmark as Associate Researcher.
He has over 18 years’ experience in community health, mental health and public health systems. He has experiences of working in humanitarian settings in Afghanistan, Burundi, Nepal, Uganda and South Sudan. He has also supported the programmes in Kenya, Vietnam, Ukraine and the USA. He co-directed the scaling up grant on Self Help Plus (SH+) in Uganda and also coordinated the Nepal program for a large multicountry consortium project called Emerging Mental Health Systems in Low- and- Middle Income Countries (EMERALD). He also coordinated the Post Research Ethics Analysis (PREA) project in Afghanistan, Nepal and South Sudan.
Dr Upadhaya’s work focuses on community mobilisation, community system strengthening, mental health systems, community mental health and policy engagement. He has published more than 30 papers in international journals and contributed in book chapters and manuals.
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Episode Transcript
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Laura May (00:11):
Hello and welcome to the Conflict Tipping podcast from Mediate.Com.
The podcast that explores socialconflict and what we can do about it.
I'm your host, Laura May,and today I have with me Dr.
Nawaraj Upadhaya.
Nawaraj is Global Mental HealthDirector at Health Rite International
New York, and Associate Researcherin the Department of Public Health
(00:34):
at the University of Copenhagen.
He has experiences of working in differentcontexts, including low and middle income
countries, as well as being educated inthe Netherlands and working in the US.
His interests include publichealth, mental health, and
psychosocial support, and.
strengthening community systems.
He is currently Integrating stressmanagement in Uganda and in South Sudan,
(00:59):
which I'm very excited hear about.
But first things first, welcome Nawaraj!
Nawaraj Upadhaya (01:04):
Thank you very much, Laura, for having me on the show.
Laura May (01:09):
I am absolutely delighted to have you here, and let's jump
straight in because I want tohear about this current project.
What actually is itthat you're working on?
Nawaraj Upadhaya (01:18):
Currently we are working on actually scaling
up a Self-Help Plus intervention.
This is an intervention that has beendeveloped by WHO and then with WHO
we have actually have piloted thisintervention in Uganda among refugees
from South Sudan, staying in theNorthern Ugandan refugee settlement.
(01:41):
So the idea is that, look, thereare many mental health problems,
psychosocial problems that are unmet.
And, you know, especially inhumanitarian settings, it is difficult
to actually provide one-to-onesupport because the specialists
are lacking there in especiallylow and middle income countries.
We have the lack of, specialistsand also the resources.
(02:03):
So actually we need it.
An intervention that can be deliveredby lay health workers, lay people,
like lay and community workers.
Together with WHO, we have designedthis lay people delivered psychosocial
intervention that can be actuallydelivered by anybody who have
(02:24):
received one week training andhave, some developed supervision.
And that can be implementedquite easily and everywhere.
So that was the idea that wedeveloped this intervention.
So it can work as a self-help and alsofacilitate it by a peer facilitator or
a facilitator at the community level.
(02:45):
It could be the village health teammember, community health volunteers,
or school teacher, or the members ofthe mother's group, anybody that has
social skills and some, inter personalskills and communication skills.
And we do not need any prior mental healthtraining to deliver this intervention.
(03:05):
So the idea was that we wanted toscale up this intervention to the
areas where specialists won't go.
Laura May (03:13):
And so what does the intervention actually entail?
like what is the contentof the intervention?
intervention?
Nawaraj Upadhaya (03:19):
Actually the intervention has five
sessions . One is grounding.
We all have, you know, emotionsthat are flying here and there,
and we get, either excited ordepressed based on the emotions.
So we actually do the grounding.
So this intervention is actually basedon Acceptance and Commitment Therapy.
We accept whatever is there, thewhatever emotion is there, we
(03:41):
accept it and then we commit toactually take action to change it.
And so it is also based on mindfulness.
Okay, so Acceptance and Commitment.
And then for that, you haveto actually ground yourself
whenever you have a problem.
The storm of emotions, youneed to ground yourself.
(04:02):
So it's called grounding.
And then after grounding, youactually also deal with the storm.
Then, you know, you have your values,how to act on the values, and then being
kind to you and being kind to others.
So anyway, five 90 minutessessions, delivered in, you
know, five weekly sessions.
(04:24):
One session per week.
And then, for five weeks.
Laura May (04:29):
I mean, something that really fascinates me about what you've just said
is these sessions are being deliveredin very difficult contexts, right?
So, conflicts, activeconflicts, and refugee camps.
And so I'm wondering what thereaction is to this session about
being kind to yourself and others.
I mean, what's the response like?
Cause I imagine I would feel verycynical if I'm in a conflict zone and
(04:50):
I'm being told to be nice to people.
How does it actually pan out?
Nawaraj Upadhaya (04:54):
Actually, we have had very positive response from all
the, participants who have attendedthis session because, you know,
look, you know, we all, no matter,you know, where we are in the um,
you know, high income countries, weactually take less care of ourself.
We are actually not kind to ourself.
We always blame ourself for, for somethingthat did not go good and something
(05:19):
that went wrong, oh, it's because of me.
Or, you know, I actuallyshould have done this.
So actually we do nottake care of ourself.
So we are not kind toourself wherever we are.
And then especially in the conflictsetting, you are, stressed with many
problems, you know, many situations.
So then you tend to blame yourself more.
(05:40):
So then actually being kind to yourself.
Okay.
Okay.
Just speak calm.
Just take some time for yourself,is actually absolutely needed
in the conflict setting.
And also being kind to others is alsoreally helping gratifying, you know,
showing gratitude to others alsohelps you to manage your own emotions.
(06:05):
Actually, I was also inmany conflict zone myself.
Like sometime I blame,okay, why did I come here?
You know, I was, looking for money.
You know, like that thatgood job that pays good.
Like, in a conflict setting.
No no, be calm, be kind to yourself,you know, you are also doing service.
You are also helping.
So it's both way . Then this is, askill to support yourself and others.
(06:31):
So to answer your question, yes, in aconflict setting, also you can, and you
should be kind to yourself and others.
And our participants havereally, experienced positive
aspect of this session.
Laura May (06:47):
That's really fascinating to me.
I mean, I had neverconsidered that before.
That aspect of, oh, if you're in aconflict, you're actually going to be
meaner to yourself than you normally are.
And I think being mean to ourselves,and that mean inner voice is very
relatable for a lot of people.
But then I guess if we look at the,non conflict context where you have
victims of violent crime, for instanceor victims more broadly, and yeah,
(07:08):
there is that theme of blaming oneself.
For the situation and being meaner tooneself and taking less care of oneself.
So, yeah.
So thank you for, showing methat this actually happens
as well in conflict zones.
It's not the conflict that isblamed for everything we also are
actually quite unkind to ourselves.
Nawaraj Upadhaya (07:25):
Actually, you know everybody, even the people in
a difficult situation, they haveresiliency, they have power to try
support themselves and support others.
So what we actually do is that, youknow, even in the most difficult
situation, you still have youragency, your power to change.
And so in our programming, we focuson the active participation of the
(07:49):
population that are affected by theconflict because they have a lot to,
give it to us in terms of programming,in terms of, you know, implementation,
in terms of, you know, researchingbecause they know that situation the best.
They are exposed by experience.
So, that is the basis, the fundamentalprinciple that we are putting that,
(08:10):
you know, everybody in the difficultsituations have power to change
and their involvement into ourprogramming is really important.
Laura May (08:22):
And so I'm just wondering who actually goes to these sessions?
So you said you're delivering the trainingso people know how to facilitate them,
but do people choose to then go, or is itsomething that they are required to do?
I mean, how do you getpeople at these sessions?
Nawaraj Upadhaya (08:37):
So, actually, first of all, we will, do, a you know, awareness
session about this intervention, likethis intervention is available there.
Like if any of are, having somestress related problem, like stress,
or you need stress management, youknow, you can actually try to come,
but then before that, actually we do abaseline assessment and then we assess
(09:01):
level of anxiety, their level of,you know, depression with the scales.
So this intervention is only for mild tomoderate stress, because it's very basic.
So we actually do the baseline assessmentand we will only take mild to moderate
level of stress or psychosocialproblems into this intervention.
And if we find somebody with a higherlevel of stress or higher level of
(09:25):
depression or or suicidal ideation, andthen we directly refer them to specialist
services and we do not involve theminto intervention because this is a
first line basic intervention, and itis helpful for only mild to moderate
problems of stress, uh, depression.
There are of course some specificcase examples, like, , the, um,
(09:48):
acceptance level are, you know, slightlydifferent in, you know, different
context because of the culture.
You know, like this is a mindfulnessbased, you know, intervention like
mindfulness is, Buddhist philosophy orsometimes sometime is quite challenging.
But there is no mention of Buddhismthere mention even even mindfulness.
So we have tried to, you know,minimize that but people know it.
(10:11):
So sometime it is, um, uh,challenging in, in terms of culture.
But once people are in the session,then actually they really like it.
So there is no problem once they'rein the session, they have started and
the dropout rate from session one tosession five is very minimal actually.
Laura May (10:31):
And what does this actually do for the people who
participate, if they go through thisprogram, there's these five sessions.
What are the outcomesfor them in their lives?
Nawaraj Upadhaya (10:41):
One outcome is that they will have reduce d symptoms
of depression, anxiety, and stress.
So there will be symptom reduction.
One.
Second, their dailyfunctioning has improved.
Actually, we have also done a researchon that, and we have found that their
symptom severity has reduced and, andthen their functioning level has improved.
(11:05):
And because of that, theyhave better family, harmony.
And also there is lessgender-based violence and
there is more communal support.
People are, also being kind tothemself and kind to others, so
that actually there is more, youknow, a greater outlook of the life.
Okay?
Life has to be lived nicely.
(11:27):
Of course.
We we all are scaredwith, you know, resources.
We all have problems.
Even the king has a problem, youknow, like, you know, so resources
are one aspect, but how you takeyour life philosophy and how do
you manage your life actually?
This intervention also talks about values.
How, what are your daily values?
What do you value?
How do you take your time foryourself, for your family?
(11:51):
How do you balance your life?
How do you manage theresources that you have?
You know, some people have, youknow, a lot of, you know, resources,
but there's still stress that theyactually take drugs and others
to actually manage their stress.
So.
Not having resources is also, a problem.
But, but you know, not having a values andacting on the values is a bigger problem.
(12:14):
So this intervention actually teachesthat you have to have a value and
you know, what is your value andhow do you act on in a balanced way.
Laura May (12:21):
You know, as you, As you're saying all this, I just
keep hearing um, I do thesefacilitations actually with CEOs and
business leaders around the world.
Where we do things like talkabout what are your values?
How do you connect to your values inyour daily life and your business?
How do you be authentic?
(12:42):
How do you practice kindness?
How do you build trust within yourselfor within your close relationships?
And typically these people I mean,they're very well resourced, right?
Like resources are not the issue.
but they do have the problems that you'veflagged, and they do still have these
stresses and they, they do still havethis disconnection within themselves.
And so, even though these are polaropposites in terms of context, it's
(13:06):
just, it's very strange for me tobe hearing them from both sides.
Nawaraj Upadhaya (13:10):
Yeah.
I think one inter interestingaspect that I will share with you,
that we did a global survey onthe psychological stress of staff.
Okay.
And actually we found out that astaff in Ukraine and a staff in other
countries, Uganda and Kenya also,you know, high income countries,
actually were equally stressed.
(13:33):
So conflict of course had some impacton the stress level, but they also
had a resiliency to actually copewith the problem in terms of accept.
Acceptance level was higher there comparedto the staff based in high income
country because their expectation was,oh, you know, it should have happened
there, but it's not happening, so, okay.
(13:53):
It's not good like that, but thereyou know, we were, you know, attacked
by our enemy, so, you know, we haveto actually, support each other.
Okay, this is a difficult time.
We should actually, support the nation.
Like that kind of acceptanceand, supportive attitude is
higher so that you can cope better,
Laura May (14:10):
mm
Nawaraj Upadhaya (14:11):
you know, when we have higher expectations, and less supportive
attitude and you you have a higher stress.
Laura May (14:19):
No, it's fascinating.
Yeah.
And so what's next for youwith these interventions?
Are you working on differentareas, different things?
Nawaraj Upadhaya (14:30):
With this intervention, we want to reach more and more people.
And more and more people in the ruralareas, in the, you know, refugee camps,
in the IDP camps, where normallythese services are not available.
So we want to one, prevent the on set of,the mental health problems becoming more
severe if they're not treated on time.
(14:52):
And we also want to actually, facilitatepeer facilitated models so that this will
be an intervention which will also havesupport network like in their community.
They'll also be discussingthe livelihood aspects.
We have indicated this interventioninto livelihood component of our partner
bRAC in Uganda, because they're thespecialists in livelihood activities,
(15:16):
and we are specialists in mentalhealth and psychosocial support.
So we have supported them to integratethis intervention into their livelihood
programs so that the refugees, theparticipants, the host communities
involved in the livelihood programcan also manage their stress, their
(15:36):
anxiety, so that they can also doa better livelihood activities.
And then they also can havebetter family functioning.
There is a connection.
So what we want to do with that,this intervention to be integrated
into the regular programming ofthe larger humanitarian actors.
So that they can reachmore and more people.
(15:57):
We as HealthRight, we are, small NGO witha limited geography, only five countries.
But if we support other humanitarianactors, the government, then they can
actually reach more and more people.
So that is our aim, actually,I will tell you that.
With this intervention, wealso developed a model that is
called Self-Help plus 360 Model.
(16:19):
So this model actually trains thegovernment bodies, the UN bodies, the
I NGOs, bodies, and other humanitarianactors to integrate this interventions,
Self-help Plus intervention,into their regular programming.
So that after one year of engagementwith us, we actually train them.
(16:39):
We adapt the interventioninto their context.
The data tracking system, thetraining and supervision system,
and competency based assessments.
So everything is done withinthis one years of engagement.
And after that, they can takeall our materials and they can do
the intervention by themselves.
(16:59):
They don't need us.
So that is the idea.
Many of them, like many of thestakeholders ask, oh, you are putting
yourself outta business because after oneyear they'll be able to run by themselves.
They may replicate the training forothers, and he will lose your business.
And we'll say, no, we actually want,of course we'll support other, partners
(17:22):
and we will have our business continued.
But the main aspect is that we wantto reach more and more people that
are in need of this intervention,and we cannot do that alone.
So we actually have, supportedMinistry of Health in Uganda,
the Brac iNGO in Uganda.
We have also supportedU N S C R in Uganda.
(17:43):
So these are the three case examplesthat we have had in this model and
all of them have been successful.
And because of that, we have nowextended our service to Amref Health
Africa in South Sudan so that weare extending and also in Ukraine.
And then we are exploring thepossibility to expand it into
Palestine, to Ghana, to Liberia.
(18:06):
Uh, we already have submitteda small proposal to support
our partner in Palestine.
Laura May (18:12):
And so tell me then about Ukraine.
So you mentioned thatyou've done some work there.
What does that look like?
Nawaraj Upadhaya (18:18):
Yeah, actually in Ukraine, uh, we, the N G O that, that
I'm working for Health International.
We actually, we are there for a longtime, since, many years um, and then
when, there was a problem in 2014,like Crimea and in eastern Ukraine,
we actually developed a psychosocialmobile team approach where we were
(18:41):
supporting the Donetsk and Luhansk regionat that time with a mobile team that
included, this psychologist, you know,health worker, nurse, you know, driver.
And then they'll go to the frontline,with a mobile car, a van, and they'll
meet the people on the frontline.
And provide basic psychosocial support,emotional support, psychoeducation.
(19:04):
And then they'll also identify peoplethat need other, advanced support.
And they'll connect that people to,to the health facilities or other
mental health care, uh, support.
That is called mobile.
Mobile mental health team.
That experience really helped us.
And actually after the the recent, youknow, Russian invasion, many donors
(19:26):
like this approach, and they askedus to expand this into other regions.
And then we expanded from 13,mobile mental health team to 83
mobile mental health team nowacross, spread across Ukraine.
And we are providing supportat the metro station bus
station, border checkpoints.
And then we also now we have includedthe lawyer in the team because we
(19:50):
needed lots of, you know, legalissues, um, of the property of, of
the the traveling to the border.
, Lots of legal issues were there.
So we have included thelawyer in that team.
So that team is now providing servicesand in the, event of lack of the
established services, our mobilemental health team is there on the spot
(20:11):
providing basic mental health support.
Laura May (20:13):
Hmm.
I love this.
It's like a little team of superheroes.
I feel like that's the team of superheroeswe all meet in our lives, right?
So we've got the nurse, we've got thedifferent psychological support, we've
got the lawyer, we're gonna be fineno matter what we encounter, I feel
Nawaraj Upadhaya (20:26):
Yeah.
We also . Included social workers,so that social worker will be dealing
with children children issues.
And we have also included the basicemergency support kit so that, we
have basic, on the physical supportalso like the material support so
that, like hygiene kit and other likebasic, you know, emergency kit and
(20:48):
then psychosocial support together.
Laura May (20:52):
And out of curiosity, are you doing any work with
Azerbaijan, Armenia and the ongoinggenocide of Nagorno Karabakh?
Is that also it?
Because it seems to be kind ofinvisible, but it's also so close
to Ukraine geographically, right?
Nawaraj Upadhaya (21:06):
Actually, we have no program there.
Uh, Of course we are directlysupporting with our knowledge that,
you know, we are also a member of theI S E Interagency Standing Committee.
That is, everywhere inthe humanitarian context.
Of course, we do share our materials.
The materials that we have adoptedand developed in Uganda are now
(21:27):
publicly available in the WHO website.
We have made them publiclyavailable so everybody can use it.
They don't need to, you know,ask for permission to us.
They're publicly there.
So, they have the whole manual,adapted for the, context with
the, screening tool and all that.
We are also providing some free, uh,advisory support . And then if they need
(21:47):
more support, then you know, they willbe, uh, paying a small fee for us to,
to support them in a, like in a designand a delivery of the intervention.
But we are also supporting them on aadvisory level support, um, free of cost.
Laura May (22:03):
So I could go to the World Health Organization website and I could
just type in the search bar, how willI how will I find these documents?
Nawaraj Upadhaya (22:11):
If you, for example, if you search Self-help
Plus in, uh, WHO website.
Then you will get the PDF thethen you will have like, you
know, the all versions are there.
You can, read it.
And if you need more informationthen you know there is also
email address that's of me.
And you can write me personallyand I'll provide more information.
(22:32):
And my colleagues also can do the same.
Laura May (22:35):
Awesome.
And so what led you to this type of work?
What was your journey that got you here?
Mm
Nawaraj Upadhaya (22:42):
Actually, um as you know, I'm from Nepal.
I have been working in the conflictduring the Maoist conflict of 10 years.
Nepal is also a poorcountry, low income country.
And you know, in many of the parts wherewhere the conflict affected, we did
not have, the mental health services.
Still, you know, mental healthservices are very limited in Nepal.
And then what I also learned is that,the people in emergency setting,
(23:05):
actually they don't need a biggermental health support, if they can
be supported, like this low intensityintervention on time, this 70, 80, 90%
of people can actually recover well.
Even without the bigger support.
The larger portion of people recoverwith basic social support, basic, you
know, food shelter and other supports,social support, and then only a few
(23:29):
percent of people, people actuallydevelop mental health problems and
they need a specialist support.
So if we can support the last portionup to 90% or up to 95% with this kind
of intervention, why shouldn't wedevelop, and actually, and support
the majority of the people that,that that can help themselves.
(23:49):
So it's a self-help tool so theycan help themselves and then we
actually reduce the burden of mentalhealth problems by implementing
this low intensity intervention.
So that was the idea.
And then luckily, I know many others,you know, were also thinking the same.
And then this is how you know,this intervention was developed
(24:10):
and we were lucky to pilot inUganda with our organisation.
And you know, we are the only oneoften now who have hands-on experience
in this intervention because thisintervention was only, you know,
publicly available last year.
So we did the piloting scale- upadaptation and the, uh, randomized
(24:34):
trial and it was all found effectiveand then now it is publicly available.
Laura May (24:41):
I mean, I definitely understand why you would do this project.
It sounds really worthwhile.
You've said it's really, reallyeffective, but I want to understand your
motivation other than that it's effective.
Why, why did this becomefor now your life's work?
Nawaraj Upadhaya (24:57):
Actually, um, my, own history that I come from a rural village
in Nepal, even far away from Kathmandu-two hours of plane flight and then many
days of, a road, a difficult road travel.
So that actually has, uh, given me akind of acceptance and commitment you
know, attitude, from the beginning.
(25:17):
And then I am also a practitionerof Vipassana meditation, which
is a mindful, meditation.
So I'm a student and I'm apractitioner of this for a long time.
And then this intervention isspecifically based on that.
So it is kind of like my own practice,my own philosophy, and then it gives
(25:39):
me satisfaction if I can help otherpeople to at least, teach them basic
skills on how to take care of themself,how to take care of their family,
and then also how to help ourself.
At least I'm very happy that inthe, in the conflict setting, in
Afghanistan, in Burundi, in SouthSudan, in Ukraine, that I have been
(26:01):
able to at least give some support tothe people that would, need the most.
So that is, gratifying,satisfying for me.
And it's also a gratitude to myteachers, to my relatives who actually
taught me this philosophy, this kindof, principal and the Buddhist custom.
(26:22):
So I also feel that, you know, it'salso gratitude to my teachers.
Laura May (26:28):
I mean, honestly, that story gave me some chills.
Imagining this little kid in thissort of rural village in Nepal.
And then now, I guess a few yearslater, a few years later out here
supporting people in a range of conflictzones and refugee camps and camps for
internally displaced people as well.
And teaching them these lessons youtook with you from your childhood.
(26:49):
I think that that's, that's somethingreally inspirational, actually.
There's something quitebeautiful about that.
Nawaraj Upadhaya (26:54):
And I think, you know, um, what I have learned myself
is that we always forget small things.
Like, you, me, everybody, wealways want to, you know, uh,
achieve big things big things.
We go for big titles, big,you know, achievement.
But we forget small, small thing.
Like I am forgetting I don't givefive minutes focus time to myself.
(27:15):
If you also, really ask, yourself, doyou really give focus time to herself?
Actually, I don't think so.
You might be looking at the news,you might be looking at something.
So we all actually forget small things.
And if we do small, smallthings, actually we can actually
achieve many things in our life.
For example, our eyes smile,and it's very important.
(27:37):
Our heart is very small,but very important.
Our mind is very small,but very important.
So we should not forgetthese small things.
The small moment, living atthe moment, moment by moment.
Accepting the reality as it is,not as you would like it to be.
So that is a problem that in lifewe have, we want things to, that we
(27:59):
want, but we don't accept as it is.
As I told you before, Ihave a stammering problem.
I explained to you that itmight be maybe a difficulty for
your listener to listen to me.
I accept it.
Of course there are problems, butI accept it and I move forward.
So the, this gives me satisfaction.
(28:20):
I'm not stressed becauseof this stammering, but you
know, I am taking action.
Laura May (28:28):
Absolutely.
I love this approach and you know,I can't help but smile a little
every time I hear you refer toAcceptance and Commitment Therapy.
Cause the, I can't remember theguy's name that came up with this
particular framing, but he was oneof my friend's PhD supervisors.
So it's a small world, right?
It's a really small world.
Like I know this therapy, How fascinating.
(28:52):
Okay, so let's zoom out a little bitif we can, cause I was wondering if
you could talk to us about the role ofmental health in conflict cause you've
mentioned, that it can exacerbate it,at least in the short term, um, I guess.
Yeah.
So can you share anyfurther insight onto this?
I know it's a very broad questionso take it where you will.
Nawaraj Upadhaya (29:12):
Okay?
Uh, let me try to answer if I can.
Look, you know, the research hasshown that in conflict situation, the
mental health problems almost doublesthe a w s estimates and other, other
research have found out that during theconflict, the mental health problems
are exacerbated, or they actuallyget even more and more problematic.
(29:34):
So, of course, and then because ofthe lack of resources and constant
movement and actually moving fromthere, home to the IDP camp or
even, in a a difficult setting.
So lots of displacement.
Displacement also brings stigmabecause you would be in a new
context, new setting, the languageissues, the adjustment issues.
(29:56):
So conflict actuallyhas many other impacts.
Not only conflict in itself, thestigma, migration , like the uh,
language issues and also the challengesinto the new system, new setting.
So mental health in conflictsetting is really important.
Every conflict programming shouldinclude consideration of mental
(30:19):
health and psychosocial aspect.
Let let me give you one example that.
I was in intervening in Koshi Riverflood in, in Nepal, and also the
Maoist conflict in Nepal, and thenTaliban conflict in Afghanistan.
And in, in this all setting.
If you don't think of the culture, if youdon't think of their you know, uh, belief
(30:42):
system, you won't be able to support them.
For example, if we are buildinga latrine in a place nearby a
funeral, or nearby, uh, thegraveyard , nobody will stay there.
And then if, if you have, so this is asmall thing, but then if you actually
consider this, then you know yourprogram is likely to gain success.
(31:06):
And then also, like if you are developinga latrine, far away from the, the light.
It'll be a problem, problem formany females to actually go there
and use it because there willbe people with ill intention.
So that you know you have to construct thelatrine as a distance where it is safe to
go, and with the light system and then,the security and privacy is maintained.
(31:31):
So small thing, but they have thehighest impact on the mental health and
psycho social oil being of the people.
Laura May (31:41):
mm.
Absolutely.
Nawaraj Upadhaya (31:41):
Yeah.
Laura May (31:43):
And so I guess, related to that in some way, in terms of our
deeper thinking is the ethical aspect.
And I understand you'vedone some work on this.
So how do we actually takeethics into account when we
are working in conflict areas?
Nawaraj Upadhaya (31:59):
I think that, you know, in any conflict situation,
we need to take the ethicalaspect, the ethical dilemma.
I have written an article with mycolleague that is published, you
know, American Journal of Ethicsthat we are actually discussing.
We have lots of dilemmas when weare working in the conflict setting.
(32:21):
In the article that we discussis that, you know, if you are a
practitioner doctor, should youprioritize medical treatment or
should you also do a research?
What should you do?
And resources are, limited.
But if you are continuing to actuallyprovide the clinical service that you
do not have the latest evidence, thenyou don't know how effective are you.
(32:47):
But if you do the research only,then people are also needing the
immediate services, lots of dilemmas.
And how to uh, disclose the HIV statusto the person in, in a conflict zone?
Like in in African context whereyour relatives also come with you.
And then so that there are manycultural aspect that actually constitute
(33:13):
the kinship, the relationship,and then that you need to look
at it in this conflict setting.
So there are lots of ethical dilemmas thatwe all, as humanitarian workers face, and
I think the organisations should have asession discuss on this dilemmas, how to
deal with them now, how to manage them.
(33:35):
At least be prepared.
Even if you cannot do it, justknow that you know you can't do it.
That's already a help,you know, a big help.
Rather than saying, ohyeah, we can't do it.
You know, what do you know?
It's better that you know, you know, youhave discussed on the ethical dilemmas.
There might be this, this problem andthese are some of the suggested solution,
(33:57):
but they may not work in the context.
So you try to find out your own solution.
But these are some of the guidelines andI think ethical concentrations should be
mentioned in any conflict work that we do.
Or any uh, disaster mental health org.
And second aspect that I think we did nottalk so much is that the caring for the
(34:22):
carers, especially the staff, frontlinestaff also need mental health support.
They are also, burnout.
They have they have experience orhave listened to very traumatic
experiences of the client.
And in the context of Ukraine,our frontline workers are also the,
survivors of the conflict, so then, inthis unique situation, we also need to
(34:44):
have a special program for frontlinestaff so that they, they can heal
themselves, so that they can heal others.
So staff care, staffwellbeing is really important.
And then actually accepting thisneed, we have developed a caring
for other carers model in Ukraine.
We actually designed this intervention,uh, by our survey research.
(35:09):
And this is an intervention that,that is peer led, peer facilitated
intervention, and then we have justfinished our pilot and we'll be doing
the global rollout in next year.
Laura May (35:24):
Amazing.
Well, that'll certainly besomething to look forward to.
It sounds, I mean, honestly, itsounds like the work you're doing
is absolutely incredible andit's innovative and important.
And so I'm just, I'm really impressed witheverything you've shared with us today,
and for others who are also impressedif they want to learn more about you
and your work, where can they find you,cause you're very difficult to Google.
Nawaraj Upadhaya (35:48):
Okay.
They can find me in theHealthRight International website.
There's a profile of me there andthey can also look me at Frontiers
in Public Health Journal whereI am the Associate Editor there.
I have also, you know, led the specialissue on, uh, mental health among
marginalized communities, at theFrontiers in Public Health Journal.
(36:12):
And then they can Google me on, youknow, Google Scholar with with my
name and they can get my, articles,
Laura May (36:19):
There are so many articles, all
Nawaraj Upadhaya (36:21):
Yes.
So many articles.
Yes, so many articles.
Laura May (36:24):
I was like, is this all the same guy, like,
does he never stop writing?
Oh my goodness.
Nawaraj Upadhaya (36:28):
Yes.
So many articles.
And I think, yeah, if they want toalso want to reach me they can write,
write me email on those articles.
I have my email mentioned andthey can reach to me and I'll
be very happy to respond.
Laura May (36:45):
Super.
Well, I'll include links to someof that as well in the episode
description so people can starttracking you down and learning more.
Look, thank you so much again for joiningme today, Nawaraj, it's been really a
pleasure and a fascinating conversation,and for everybody else, until next time,
this is Laura May with the ConflictTipping Podcast from Mediate.com.
Hello and welcome to the Conflict Tipping podcast from Mediate.Com.
The podcast that explores socialconflict and what we can do about it.
I'm your host, Laura May,and today I have with me Dr.
Nawaraj Upadhaya.
Nawaraj is Global Mental HealthDirector at Health Rite International
New York, and Associate Researcherin the Department of Public Health
(00:34):
at the University of Copenhagen.
He has experiences of working in differentcontexts, including low and middle income
countries, as well as being educated inthe Netherlands and working in the US.
His interests include publichealth, mental health, and
psychosocial support, and.
strengthening community systems.
He is currently Integrating stressmanagement in Uganda and in South Sudan,
(00:59):
which I'm very excited hear about.
But first things first, welcome Nawaraj!
Nawaraj Upadhaya (01:04):
Thank you very much, Laura, for having me on the show.
Laura May (01:09):
I am absolutely delighted to have you here, and let's jump
straight in because I want tohear about this current project.
What actually is itthat you're working on?
Nawaraj Upadhaya (01:18):
Currently we are working on actually scaling
up a Self-Help Plus intervention.
This is an intervention that has beendeveloped by WHO and then with WHO
we have actually have piloted thisintervention in Uganda among refugees
from South Sudan, staying in theNorthern Ugandan refugee settlement.
(01:41):
So the idea is that, look, thereare many mental health problems,
psychosocial problems that are unmet.
And, you know, especially inhumanitarian settings, it is difficult
to actually provide one-to-onesupport because the specialists
are lacking there in especiallylow and middle income countries.
We have the lack of, specialistsand also the resources.
(02:03):
So actually we need it.
An intervention that can be deliveredby lay health workers, lay people,
like lay and community workers.
Together with WHO, we have designedthis lay people delivered psychosocial
intervention that can be actuallydelivered by anybody who have
(02:24):
received one week training andhave, some developed supervision.
And that can be implementedquite easily and everywhere.
So that was the idea that wedeveloped this intervention.
So it can work as a self-help and alsofacilitate it by a peer facilitator or
a facilitator at the community level.
(02:45):
It could be the village health teammember, community health volunteers,
or school teacher, or the members ofthe mother's group, anybody that has
social skills and some, inter personalskills and communication skills.
And we do not need any prior mental healthtraining to deliver this intervention.
(03:05):
So the idea was that we wanted toscale up this intervention to the
areas where specialists won't go.
Laura May (03:13):
And so what does the intervention actually entail?
like what is the contentof the intervention?
intervention?
Nawaraj Upadhaya (03:19):
Actually the intervention has five
sessions . One is grounding.
We all have, you know, emotionsthat are flying here and there,
and we get, either excited ordepressed based on the emotions.
So we actually do the grounding.
So this intervention is actually basedon Acceptance and Commitment Therapy.
We accept whatever is there, thewhatever emotion is there, we
(03:41):
accept it and then we commit toactually take action to change it.
And so it is also based on mindfulness.
Okay, so Acceptance and Commitment.
And then for that, you haveto actually ground yourself
whenever you have a problem.
The storm of emotions, youneed to ground yourself.
(04:02):
So it's called grounding.
And then after grounding, youactually also deal with the storm.
Then, you know, you have your values,how to act on the values, and then being
kind to you and being kind to others.
So anyway, five 90 minutessessions, delivered in, you
know, five weekly sessions.
(04:24):
One session per week.
And then, for five weeks.
Laura May (04:29):
I mean, something that really fascinates me about what you've just said
is these sessions are being deliveredin very difficult contexts, right?
So, conflicts, activeconflicts, and refugee camps.
And so I'm wondering what thereaction is to this session about
being kind to yourself and others.
I mean, what's the response like?
Cause I imagine I would feel verycynical if I'm in a conflict zone and
(04:50):
I'm being told to be nice to people.
How does it actually pan out?
Nawaraj Upadhaya (04:54):
Actually, we have had very positive response from all
the, participants who have attendedthis session because, you know,
look, you know, we all, no matter,you know, where we are in the um,
you know, high income countries, weactually take less care of ourself.
We are actually not kind to ourself.
We always blame ourself for, for somethingthat did not go good and something
(05:19):
that went wrong, oh, it's because of me.
Or, you know, I actuallyshould have done this.
So actually we do nottake care of ourself.
So we are not kind toourself wherever we are.
And then especially in the conflictsetting, you are, stressed with many
problems, you know, many situations.
So then you tend to blame yourself more.
(05:40):
So then actually being kind to yourself.
Okay.
Okay.
Just speak calm.
Just take some time for yourself,is actually absolutely needed
in the conflict setting.
And also being kind to others is alsoreally helping gratifying, you know,
showing gratitude to others alsohelps you to manage your own emotions.
(06:05):
Actually, I was also inmany conflict zone myself.
Like sometime I blame,okay, why did I come here?
You know, I was, looking for money.
You know, like that thatgood job that pays good.
Like, in a conflict setting.
No no, be calm, be kind to yourself,you know, you are also doing service.
You are also helping.
So it's both way . Then this is, askill to support yourself and others.
(06:31):
So to answer your question, yes, in aconflict setting, also you can, and you
should be kind to yourself and others.
And our participants havereally, experienced positive
aspect of this session.
Laura May (06:47):
That's really fascinating to me.
I mean, I had neverconsidered that before.
That aspect of, oh, if you're in aconflict, you're actually going to be
meaner to yourself than you normally are.
And I think being mean to ourselves,and that mean inner voice is very
relatable for a lot of people.
But then I guess if we look at the,non conflict context where you have
victims of violent crime, for instanceor victims more broadly, and yeah,
(07:08):
there is that theme of blaming oneself.
For the situation and being meaner tooneself and taking less care of oneself.
So, yeah.
So thank you for, showing methat this actually happens
as well in conflict zones.
It's not the conflict that isblamed for everything we also are
actually quite unkind to ourselves.
Nawaraj Upadhaya (07:25):
Actually, you know everybody, even the people in
a difficult situation, they haveresiliency, they have power to try
support themselves and support others.
So what we actually do is that, youknow, even in the most difficult
situation, you still have youragency, your power to change.
And so in our programming, we focuson the active participation of the
(07:49):
population that are affected by theconflict because they have a lot to,
give it to us in terms of programming,in terms of, you know, implementation,
in terms of, you know, researchingbecause they know that situation the best.
They are exposed by experience.
So, that is the basis, the fundamentalprinciple that we are putting that,
(08:10):
you know, everybody in the difficultsituations have power to change
and their involvement into ourprogramming is really important.
Laura May (08:22):
And so I'm just wondering who actually goes to these sessions?
So you said you're delivering the trainingso people know how to facilitate them,
but do people choose to then go, or is itsomething that they are required to do?
I mean, how do you getpeople at these sessions?
Nawaraj Upadhaya (08:37):
So, actually, first of all, we will, do, a you know, awareness
session about this intervention, likethis intervention is available there.
Like if any of are, having somestress related problem, like stress,
or you need stress management, youknow, you can actually try to come,
but then before that, actually we do abaseline assessment and then we assess
(09:01):
level of anxiety, their level of,you know, depression with the scales.
So this intervention is only for mild tomoderate stress, because it's very basic.
So we actually do the baseline assessmentand we will only take mild to moderate
level of stress or psychosocialproblems into this intervention.
And if we find somebody with a higherlevel of stress or higher level of
(09:25):
depression or or suicidal ideation, andthen we directly refer them to specialist
services and we do not involve theminto intervention because this is a
first line basic intervention, and itis helpful for only mild to moderate
problems of stress, uh, depression.
There are of course some specificcase examples, like, , the, um,
(09:48):
acceptance level are, you know, slightlydifferent in, you know, different
context because of the culture.
You know, like this is a mindfulnessbased, you know, intervention like
mindfulness is, Buddhist philosophy orsometimes sometime is quite challenging.
But there is no mention of Buddhismthere mention even even mindfulness.
So we have tried to, you know,minimize that but people know it.
(10:11):
So sometime it is, um, uh,challenging in, in terms of culture.
But once people are in the session,then actually they really like it.
So there is no problem once they'rein the session, they have started and
the dropout rate from session one tosession five is very minimal actually.
Laura May (10:31):
And what does this actually do for the people who
participate, if they go through thisprogram, there's these five sessions.
What are the outcomesfor them in their lives?
Nawaraj Upadhaya (10:41):
One outcome is that they will have reduce d symptoms
of depression, anxiety, and stress.
So there will be symptom reduction.
One.
Second, their dailyfunctioning has improved.
Actually, we have also done a researchon that, and we have found that their
symptom severity has reduced and, andthen their functioning level has improved.
(11:05):
And because of that, theyhave better family, harmony.
And also there is lessgender-based violence and
there is more communal support.
People are, also being kind tothemself and kind to others, so
that actually there is more, youknow, a greater outlook of the life.
Okay?
Life has to be lived nicely.
(11:27):
Of course.
We we all are scaredwith, you know, resources.
We all have problems.
Even the king has a problem, youknow, like, you know, so resources
are one aspect, but how you takeyour life philosophy and how do
you manage your life actually?
This intervention also talks about values.
How, what are your daily values?
What do you value?
How do you take your time foryourself, for your family?
(11:51):
How do you balance your life?
How do you manage theresources that you have?
You know, some people have, youknow, a lot of, you know, resources,
but there's still stress that theyactually take drugs and others
to actually manage their stress.
So.
Not having resources is also, a problem.
But, but you know, not having a values andacting on the values is a bigger problem.
(12:14):
So this intervention actually teachesthat you have to have a value and
you know, what is your value andhow do you act on in a balanced way.
Laura May (12:21):
You know, as you, As you're saying all this, I just
keep hearing um, I do thesefacilitations actually with CEOs and
business leaders around the world.
Where we do things like talkabout what are your values?
How do you connect to your values inyour daily life and your business?
How do you be authentic?
(12:42):
How do you practice kindness?
How do you build trust within yourselfor within your close relationships?
And typically these people I mean,they're very well resourced, right?
Like resources are not the issue.
but they do have the problems that you'veflagged, and they do still have these
stresses and they, they do still havethis disconnection within themselves.
And so, even though these are polaropposites in terms of context, it's
(13:06):
just, it's very strange for me tobe hearing them from both sides.
Nawaraj Upadhaya (13:10):
Yeah.
I think one inter interestingaspect that I will share with you,
that we did a global survey onthe psychological stress of staff.
Okay.
And actually we found out that astaff in Ukraine and a staff in other
countries, Uganda and Kenya also,you know, high income countries,
actually were equally stressed.
(13:33):
So conflict of course had some impacton the stress level, but they also
had a resiliency to actually copewith the problem in terms of accept.
Acceptance level was higher there comparedto the staff based in high income
country because their expectation was,oh, you know, it should have happened
there, but it's not happening, so, okay.
(13:53):
It's not good like that, but thereyou know, we were, you know, attacked
by our enemy, so, you know, we haveto actually, support each other.
Okay, this is a difficult time.
We should actually, support the nation.
Like that kind of acceptanceand, supportive attitude is
higher so that you can cope better,
Laura May (14:10):
mm
Nawaraj Upadhaya (14:11):
you know, when we have higher expectations, and less supportive
attitude and you you have a higher stress.
Laura May (14:19):
No, it's fascinating.
Yeah.
And so what's next for youwith these interventions?
Are you working on differentareas, different things?
Nawaraj Upadhaya (14:30):
With this intervention, we want to reach more and more people.
And more and more people in the ruralareas, in the, you know, refugee camps,
in the IDP camps, where normallythese services are not available.
So we want to one, prevent the on set of,the mental health problems becoming more
severe if they're not treated on time.
(14:52):
And we also want to actually, facilitatepeer facilitated models so that this will
be an intervention which will also havesupport network like in their community.
They'll also be discussingthe livelihood aspects.
We have indicated this interventioninto livelihood component of our partner
bRAC in Uganda, because they're thespecialists in livelihood activities,
(15:16):
and we are specialists in mentalhealth and psychosocial support.
So we have supported them to integratethis intervention into their livelihood
programs so that the refugees, theparticipants, the host communities
involved in the livelihood programcan also manage their stress, their
(15:36):
anxiety, so that they can also doa better livelihood activities.
And then they also can havebetter family functioning.
There is a connection.
So what we want to do with that,this intervention to be integrated
into the regular programming ofthe larger humanitarian actors.
So that they can reachmore and more people.
(15:57):
We as HealthRight, we are, small NGO witha limited geography, only five countries.
But if we support other humanitarianactors, the government, then they can
actually reach more and more people.
So that is our aim, actually,I will tell you that.
With this intervention, wealso developed a model that is
called Self-Help plus 360 Model.
(16:19):
So this model actually trains thegovernment bodies, the UN bodies, the
I NGOs, bodies, and other humanitarianactors to integrate this interventions,
Self-help Plus intervention,into their regular programming.
So that after one year of engagementwith us, we actually train them.
(16:39):
We adapt the interventioninto their context.
The data tracking system, thetraining and supervision system,
and competency based assessments.
So everything is done withinthis one years of engagement.
And after that, they can takeall our materials and they can do
the intervention by themselves.
(16:59):
They don't need us.
So that is the idea.
Many of them, like many of thestakeholders ask, oh, you are putting
yourself outta business because after oneyear they'll be able to run by themselves.
They may replicate the training forothers, and he will lose your business.
And we'll say, no, we actually want,of course we'll support other, partners
(17:22):
and we will have our business continued.
But the main aspect is that we wantto reach more and more people that
are in need of this intervention,and we cannot do that alone.
So we actually have, supportedMinistry of Health in Uganda,
the Brac iNGO in Uganda.
We have also supportedU N S C R in Uganda.
(17:43):
So these are the three case examplesthat we have had in this model and
all of them have been successful.
And because of that, we have nowextended our service to Amref Health
Africa in South Sudan so that weare extending and also in Ukraine.
And then we are exploring thepossibility to expand it into
Palestine, to Ghana, to Liberia.
(18:06):
Uh, we already have submitteda small proposal to support
our partner in Palestine.
Laura May (18:12):
And so tell me then about Ukraine.
So you mentioned thatyou've done some work there.
What does that look like?
Nawaraj Upadhaya (18:18):
Yeah, actually in Ukraine, uh, we, the N G O that, that
I'm working for Health International.
We actually, we are there for a longtime, since, many years um, and then
when, there was a problem in 2014,like Crimea and in eastern Ukraine,
we actually developed a psychosocialmobile team approach where we were
(18:41):
supporting the Donetsk and Luhansk regionat that time with a mobile team that
included, this psychologist, you know,health worker, nurse, you know, driver.
And then they'll go to the frontline,with a mobile car, a van, and they'll
meet the people on the frontline.
And provide basic psychosocial support,emotional support, psychoeducation.
(19:04):
And then they'll also identify peoplethat need other, advanced support.
And they'll connect that people to,to the health facilities or other
mental health care, uh, support.
That is called mobile.
Mobile mental health team.
That experience really helped us.
And actually after the the recent, youknow, Russian invasion, many donors
(19:26):
like this approach, and they askedus to expand this into other regions.
And then we expanded from 13,mobile mental health team to 83
mobile mental health team nowacross, spread across Ukraine.
And we are providing supportat the metro station bus
station, border checkpoints.
And then we also now we have includedthe lawyer in the team because we
(19:50):
needed lots of, you know, legalissues, um, of the property of, of
the the traveling to the border.
, Lots of legal issues were there.
So we have included thelawyer in that team.
So that team is now providing servicesand in the, event of lack of the
established services, our mobilemental health team is there on the spot
(20:11):
providing basic mental health support.
Laura May (20:13):
Hmm.
I love this.
It's like a little team of superheroes.
I feel like that's the team of superheroeswe all meet in our lives, right?
So we've got the nurse, we've got thedifferent psychological support, we've
got the lawyer, we're gonna be fineno matter what we encounter, I feel
Nawaraj Upadhaya (20:26):
Yeah.
We also . Included social workers,so that social worker will be dealing
with children children issues.
And we have also included the basicemergency support kit so that, we
have basic, on the physical supportalso like the material support so
that, like hygiene kit and other likebasic, you know, emergency kit and
(20:48):
then psychosocial support together.
Laura May (20:52):
And out of curiosity, are you doing any work with
Azerbaijan, Armenia and the ongoinggenocide of Nagorno Karabakh?
Is that also it?
Because it seems to be kind ofinvisible, but it's also so close
to Ukraine geographically, right?
Nawaraj Upadhaya (21:06):
Actually, we have no program there.
Uh, Of course we are directlysupporting with our knowledge that,
you know, we are also a member of theI S E Interagency Standing Committee.
That is, everywhere inthe humanitarian context.
Of course, we do share our materials.
The materials that we have adoptedand developed in Uganda are now
(21:27):
publicly available in the WHO website.
We have made them publiclyavailable so everybody can use it.
They don't need to, you know,ask for permission to us.
They're publicly there.
So, they have the whole manual,adapted for the, context with
the, screening tool and all that.
We are also providing some free, uh,advisory support . And then if they need
(21:47):
more support, then you know, they willbe, uh, paying a small fee for us to,
to support them in a, like in a designand a delivery of the intervention.
But we are also supporting them on aadvisory level support, um, free of cost.
Laura May (22:03):
So I could go to the World Health Organization website and I could
just type in the search bar, how willI how will I find these documents?
Nawaraj Upadhaya (22:11):
If you, for example, if you search Self-help
Plus in, uh, WHO website.
Then you will get the PDF thethen you will have like, you
know, the all versions are there.
You can, read it.
And if you need more informationthen you know there is also
email address that's of me.
And you can write me personallyand I'll provide more information.
(22:32):
And my colleagues also can do the same.
Laura May (22:35):
Awesome.
And so what led you to this type of work?
What was your journey that got you here?
Mm
Nawaraj Upadhaya (22:42):
Actually, um as you know, I'm from Nepal.
I have been working in the conflictduring the Maoist conflict of 10 years.
Nepal is also a poorcountry, low income country.
And you know, in many of the parts wherewhere the conflict affected, we did
not have, the mental health services.
Still, you know, mental healthservices are very limited in Nepal.
And then what I also learned is that,the people in emergency setting,
(23:05):
actually they don't need a biggermental health support, if they can
be supported, like this low intensityintervention on time, this 70, 80, 90%
of people can actually recover well.
Even without the bigger support.
The larger portion of people recoverwith basic social support, basic, you
know, food shelter and other supports,social support, and then only a few
(23:29):
percent of people, people actuallydevelop mental health problems and
they need a specialist support.
So if we can support the last portionup to 90% or up to 95% with this kind
of intervention, why shouldn't wedevelop, and actually, and support
the majority of the people that,that that can help themselves.
(23:49):
So it's a self-help tool so theycan help themselves and then we
actually reduce the burden of mentalhealth problems by implementing
this low intensity intervention.
So that was the idea.
And then luckily, I know many others,you know, were also thinking the same.
And then this is how you know,this intervention was developed
(24:10):
and we were lucky to pilot inUganda with our organisation.
And you know, we are the only oneoften now who have hands-on experience
in this intervention because thisintervention was only, you know,
publicly available last year.
So we did the piloting scale- upadaptation and the, uh, randomized
(24:34):
trial and it was all found effectiveand then now it is publicly available.
Laura May (24:41):
I mean, I definitely understand why you would do this project.
It sounds really worthwhile.
You've said it's really, reallyeffective, but I want to understand your
motivation other than that it's effective.
Why, why did this becomefor now your life's work?
Nawaraj Upadhaya (24:57):
Actually, um, my, own history that I come from a rural village
in Nepal, even far away from Kathmandu-two hours of plane flight and then many
days of, a road, a difficult road travel.
So that actually has, uh, given me akind of acceptance and commitment you
know, attitude, from the beginning.
(25:17):
And then I am also a practitionerof Vipassana meditation, which
is a mindful, meditation.
So I'm a student and I'm apractitioner of this for a long time.
And then this intervention isspecifically based on that.
So it is kind of like my own practice,my own philosophy, and then it gives
(25:39):
me satisfaction if I can help otherpeople to at least, teach them basic
skills on how to take care of themself,how to take care of their family,
and then also how to help ourself.
At least I'm very happy that inthe, in the conflict setting, in
Afghanistan, in Burundi, in SouthSudan, in Ukraine, that I have been
(26:01):
able to at least give some support tothe people that would, need the most.
So that is, gratifying,satisfying for me.
And it's also a gratitude to myteachers, to my relatives who actually
taught me this philosophy, this kindof, principal and the Buddhist custom.
(26:22):
So I also feel that, you know, it'salso gratitude to my teachers.
Laura May (26:28):
I mean, honestly, that story gave me some chills.
Imagining this little kid in thissort of rural village in Nepal.
And then now, I guess a few yearslater, a few years later out here
supporting people in a range of conflictzones and refugee camps and camps for
internally displaced people as well.
And teaching them these lessons youtook with you from your childhood.
(26:49):
I think that that's, that's somethingreally inspirational, actually.
There's something quitebeautiful about that.
Nawaraj Upadhaya (26:54):
And I think, you know, um, what I have learned myself
is that we always forget small things.
Like, you, me, everybody, wealways want to, you know, uh,
achieve big things big things.
We go for big titles, big,you know, achievement.
But we forget small, small thing.
Like I am forgetting I don't givefive minutes focus time to myself.
(27:15):
If you also, really ask, yourself, doyou really give focus time to herself?
Actually, I don't think so.
You might be looking at the news,you might be looking at something.
So we all actually forget small things.
And if we do small, smallthings, actually we can actually
achieve many things in our life.
For example, our eyes smile,and it's very important.
(27:37):
Our heart is very small,but very important.
Our mind is very small,but very important.
So we should not forgetthese small things.
The small moment, living atthe moment, moment by moment.
Accepting the reality as it is,not as you would like it to be.
So that is a problem that in lifewe have, we want things to, that we
(27:59):
want, but we don't accept as it is.
As I told you before, Ihave a stammering problem.
I explained to you that itmight be maybe a difficulty for
your listener to listen to me.
I accept it.
Of course there are problems, butI accept it and I move forward.
So the, this gives me satisfaction.
(28:20):
I'm not stressed becauseof this stammering, but you
know, I am taking action.
Laura May (28:28):
Absolutely.
I love this approach and you know,I can't help but smile a little
every time I hear you refer toAcceptance and Commitment Therapy.
Cause the, I can't remember theguy's name that came up with this
particular framing, but he was oneof my friend's PhD supervisors.
So it's a small world, right?
It's a really small world.
Like I know this therapy, How fascinating.
(28:52):
Okay, so let's zoom out a little bitif we can, cause I was wondering if
you could talk to us about the role ofmental health in conflict cause you've
mentioned, that it can exacerbate it,at least in the short term, um, I guess.
Yeah.
So can you share anyfurther insight onto this?
I know it's a very broad questionso take it where you will.
Nawaraj Upadhaya (29:12):
Okay?
Uh, let me try to answer if I can.
Look, you know, the research hasshown that in conflict situation, the
mental health problems almost doublesthe a w s estimates and other, other
research have found out that during theconflict, the mental health problems
are exacerbated, or they actuallyget even more and more problematic.
(29:34):
So, of course, and then because ofthe lack of resources and constant
movement and actually moving fromthere, home to the IDP camp or
even, in a a difficult setting.
So lots of displacement.
Displacement also brings stigmabecause you would be in a new
context, new setting, the languageissues, the adjustment issues.
(29:56):
So conflict actuallyhas many other impacts.
Not only conflict in itself, thestigma, migration , like the uh,
language issues and also the challengesinto the new system, new setting.
So mental health in conflictsetting is really important.
Every conflict programming shouldinclude consideration of mental
(30:19):
health and psychosocial aspect.
Let let me give you one example that.
I was in intervening in Koshi Riverflood in, in Nepal, and also the
Maoist conflict in Nepal, and thenTaliban conflict in Afghanistan.
And in, in this all setting.
If you don't think of the culture, if youdon't think of their you know, uh, belief
(30:42):
system, you won't be able to support them.
For example, if we are buildinga latrine in a place nearby a
funeral, or nearby, uh, thegraveyard , nobody will stay there.
And then if, if you have, so this is asmall thing, but then if you actually
consider this, then you know yourprogram is likely to gain success.
(31:06):
And then also, like if you are developinga latrine, far away from the, the light.
It'll be a problem, problem formany females to actually go there
and use it because there willbe people with ill intention.
So that you know you have to construct thelatrine as a distance where it is safe to
go, and with the light system and then,the security and privacy is maintained.
(31:31):
So small thing, but they have thehighest impact on the mental health and
psycho social oil being of the people.
Laura May (31:41):
mm.
Absolutely.
Nawaraj Upadhaya (31:41):
Yeah.
Laura May (31:43):
And so I guess, related to that in some way, in terms of our
deeper thinking is the ethical aspect.
And I understand you'vedone some work on this.
So how do we actually takeethics into account when we
are working in conflict areas?
Nawaraj Upadhaya (31:59):
I think that, you know, in any conflict situation,
we need to take the ethicalaspect, the ethical dilemma.
I have written an article with mycolleague that is published, you
know, American Journal of Ethicsthat we are actually discussing.
We have lots of dilemmas when weare working in the conflict setting.
(32:21):
In the article that we discussis that, you know, if you are a
practitioner doctor, should youprioritize medical treatment or
should you also do a research?
What should you do?
And resources are, limited.
But if you are continuing to actuallyprovide the clinical service that you
do not have the latest evidence, thenyou don't know how effective are you.
(32:47):
But if you do the research only,then people are also needing the
immediate services, lots of dilemmas.
And how to uh, disclose the HIV statusto the person in, in a conflict zone?
Like in in African context whereyour relatives also come with you.
And then so that there are manycultural aspect that actually constitute
(33:13):
the kinship, the relationship,and then that you need to look
at it in this conflict setting.
So there are lots of ethical dilemmas thatwe all, as humanitarian workers face, and
I think the organisations should have asession discuss on this dilemmas, how to
deal with them now, how to manage them.
(33:35):
At least be prepared.
Even if you cannot do it, justknow that you know you can't do it.
That's already a help,you know, a big help.
Rather than saying, ohyeah, we can't do it.
You know, what do you know?
It's better that you know, you know, youhave discussed on the ethical dilemmas.
There might be this, this problem andthese are some of the suggested solution,
(33:57):
but they may not work in the context.
So you try to find out your own solution.
But these are some of the guidelines andI think ethical concentrations should be
mentioned in any conflict work that we do.
Or any uh, disaster mental health org.
And second aspect that I think we did nottalk so much is that the caring for the
(34:22):
carers, especially the staff, frontlinestaff also need mental health support.
They are also, burnout.
They have they have experience orhave listened to very traumatic
experiences of the client.
And in the context of Ukraine,our frontline workers are also the,
survivors of the conflict, so then, inthis unique situation, we also need to
(34:44):
have a special program for frontlinestaff so that they, they can heal
themselves, so that they can heal others.
So staff care, staffwellbeing is really important.
And then actually accepting thisneed, we have developed a caring
for other carers model in Ukraine.
We actually designed this intervention,uh, by our survey research.
(35:09):
And this is an intervention that,that is peer led, peer facilitated
intervention, and then we have justfinished our pilot and we'll be doing
the global rollout in next year.
Laura May (35:24):
Amazing.
Well, that'll certainly besomething to look forward to.
It sounds, I mean, honestly, itsounds like the work you're doing
is absolutely incredible andit's innovative and important.
And so I'm just, I'm really impressed witheverything you've shared with us today,
and for others who are also impressedif they want to learn more about you
and your work, where can they find you,cause you're very difficult to Google.
Nawaraj Upadhaya (35:48):
Okay.
They can find me in theHealthRight International website.
There's a profile of me there andthey can also look me at Frontiers
in Public Health Journal whereI am the Associate Editor there.
I have also, you know, led the specialissue on, uh, mental health among
marginalized communities, at theFrontiers in Public Health Journal.
(36:12):
And then they can Google me on, youknow, Google Scholar with with my
name and they can get my, articles,
Laura May (36:19):
There are so many articles, all
Nawaraj Upadhaya (36:21):
Yes.
So many articles.
Yes, so many articles.
Laura May (36:24):
I was like, is this all the same guy, like,
does he never stop writing?
Oh my goodness.
Nawaraj Upadhaya (36:28):
Yes.
So many articles.
And I think, yeah, if they want toalso want to reach me they can write,
write me email on those articles.
I have my email mentioned andthey can reach to me and I'll
be very happy to respond.
Laura May (36:45):
Super.
Well, I'll include links to someof that as well in the episode
description so people can starttracking you down and learning more.
Look, thank you so much again for joiningme today, Nawaraj, it's been really a
pleasure and a fascinating conversation,and for everybody else, until next time,
this is Laura May with the ConflictTipping Podcast from Mediate.com.
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