Current, Planned, and Recently Completed Projects

Ken Miller, Ph.D.
Associate Professor of Psychology
Pomona College

"Unholy Ground: Life, Death, and Survival in a Sri Lankan Village"
To see the website for the film Unholy Ground, click here.

This documentary, currently in the post-production stage, examines the impact of a massacre that took place in the remote village of Gonagala, in southeastern Sri Lanka, as part of the country's ongoing civil war. On the night of September 17-18, 1999, 300 members of the Tamil Tigers entered Gonagala and slaughtered 44 villagers in their home, as well as several visitors from outside the village.  In this film, we examine the ways in which survivors of the massacre have sought to come to terms with their profound experiences of loss. The documentary includes interviews with numerous villagers, who lost between one and nine family members during the massacre. This story of a Sinhalese village in the southeast is no doubt mirrored in numerous Tamil villages in the north and northeast, where, during the height of the armed conflict, civilians dealt daily with aerial cluster bombs, detention and torture. This documentary is a tribute to victims and survivors on both sides, who often suffer unheard by the outside world.

Credits
Written, Produced, and Directed by Ken Miller
Co-producers: Jagath Ranawake, S. Manohaari Habaragamuwa
Editor: Odell
Camera: Sampath Searasinghe and Ken Miller
Camera Assistant:  Nalinda Deshapriya
Translator: Sulani Perera
Additional Translators: Gaithri Fernando, Jagath Ranawake
Interviewers: Balapuvaduge Chanika Niroshani Rupasingha, Hiniduma Liyanage Grece Kamalawathi, Gaithri Fernando, Ken Miller
Still Photographers: Kariyawasam Thanyhirilage Jayalal Sampath, Kekulawala Ralalage Deepal Prasad Chandika, Jude, Ken Miller
Creative Consultants: Sulani Perera, Gaithri Fernando
Transportation: The Center for Psychosocial Care, Ampara
Funding Provided by The Hirsch Foundation, Pomona College, and Lillian Y. Kaplan
 

Psychosocial Wellbeing of Afghan Refugee Women in the United States
Research Team: Razia Askaryar, Psy.D., Proshat Shekarloo, & Hosai Ehsan

Advisory Board: Najia Hamid, Executive Director, Afghan Elderly Association; Dr. Lisa Goodman, Associate Professor of Counseling, Boston College; Freed Wardak, President of the Society of Afghan Professionals and CEO, Home Financial Group

This mixed-methods study is integrating focus groups, key informant interviews, and a community survey to examine the psychosocial wellbeing and mental health challenges facing Afghan refugee women in northern California. A sub-focus focus within the larger study is on the experience of domestic violence, with the aims of identifying local beliefs regarding the causes and correlates of intimate partner violence, understanding ecological factors that shape the experience of such violence, and identifying potential solutions that make sense within the sociocultural context of the Afghan community.

 

The Impact of Daily Stressors and War Experiences on Mental Health in Afghanistan
&
Psychological Trauma Among Afghans

Principal Investigator: Ken Miller, Ph.D.   Co-Investigators: Patricia Omidian, Ph.D. and Aziz Yaqubi

This study examined the relative contribution of daily stressors and war experiences to levels of symptomatology and psychosocial functioning in a sample of 320 adults (160 women and 160 men) in Afghanistan's capital city of Kabul. measures included the Afghan Symptom Checklist (ASCL), the Afghan Daily Stressors Scale (the ADSS, developed for this study), the Afghan War Experiences Scale (AWES), the WHO DAS II (a measure of disability), the Hopkins Symptom Checklist (HSCL), and the Impact of Events Scale-Revised (IES-R). Data were collected in December 2005 - January 2006.

The rationale for studying daily stressors experienced by Afghans lies in the growing realization that prior exposure to war-related violence and loss accounts for only a part of the variance in the mental health status of war-affected populations. Daily stressors such as poverty, family conflict, health problems, unemployment, social isolation, air pollution, and crime exert a significant effect on people's stress levels, and represent important foci for mental health and psychosocial interventions. Such stressors invariably call for a reconceptualization of mental health work, transcending traditional notions of change-the-person strategies to include change-the-setting interventions that empower people to alter stress-inducing aspects of their daily environments. This does not negate the vital importance of helping people cope with experiences of war-related trauma and loss through a variety of psychological and psychosocial interventions; it merely suggests the need to complement traditional clinical approaches with community-based (ecological) intervention strategies.

Paper #1 (currently under review): Miller, K., Omidian, P., Yzqubi, A., Daudzai, H., Nasiri, M., Bakhtyari, M.B., Quraishi, N., Usmankhil, S., & Sultani, Z.  Daily stressors, war experiences, and mental health in Afghanistan.

Abstract:
Working in Afghanistan’s capital city of Kabul, the authors assessed the relative contribution of daily stressors and war-related experiences to several mental health outcomes, including depression, anxiety, PTSD, psychosocial functioning, and an indigenous Afghan measure of general psychological distress. As hypothesized, daily stressors accounted for a greater amount of variance in depression, anxiety, general distress, and functioning than war experiences. Daily stressors and war experiences contributed equally to levels of PTSD symptoms, with daily stressors moderating the relationship between war experiences and PTSD; the relationship between war experiences and PTSD was significant only for people reporting a high level of daily stressors. The implications of these findings for research and intervention in conflict and post-conflict settings are discussed.

A second focus of this study was on examining the prevalence, factor structure, and salience of PTSD symptoms among Afghans. It has been assumed by several researchers that PTSD is a critical construct that should be prioritized in research with war-affected populations. However, PTSD is a largely western construction, and its applicability in non-western cultural contexts has received little attention. Nor have researchers assessed the extent to which PTSD, even when present, is in fact salient or meaningful, relative to other forms of distress, whether transcultural or culturally specific. The present study was designed to address this empirical gap.

Paper #2 (currently under review): Miller, K., Kulkarni, M., Omidian, P., & Yaqubi, A. The validity and clinical utility of Post-traumatic Stress Disorder in Afghanistan.

Abstract:
This study examined the construct validity of Post-traumatic Stress Disorder among 320 adults in Afghanistan. Findings support the validity of PTSD in this cultural context: PTSD symptoms were highly prevalent, reflected a unitary latent construct, and correlated as expected with exposure to traumatic stress. A confirmatory factr analysis found that the factor structure of PTSD symptoms did not fit the DSM IV 3-factor model; only 1 factor, Hyperarousal, emerged clearly from an exploratory factor analysis. In contrast to our findings regarding the construct validity of PTSD, little support was found for the clinical utility of PTSD in Afghanistan. Other types of psychiatric symptomatology, including depression and a culturally specific measure of general distress, correlated more highly with traumatic stress than did PTSD; and PTSD accounted for limited variance in psychosocial functioning beyond that explained by depression and general distress. Implications for research and intervention are considered.
 

Help-Seeking Pathways Among Bosnian Refugees
Principal Investigator: Ken Miller, Ph.D.
Research Team: Aisa Sadikovic, MD, Suad Sadikovic, MD, Denin Sahovic

This study is using qualitative methods (ethnography, semi-structured interviews, participant-observation) to examine factors affecting the use of both formal and informal sources of psychological assistance, as well as barriers to the use of mental health services, among Bosnian refugees in the greater San Jose area. Data collection has been completed and data analysis is currently underway.

The Afghan Symptom Checklist: A Field Study of Mental Health in Kabul, Afghanistan
Principal Investigator: Ken Miller, Ph.D.   Co-Investigator: Patricia Omidian, Ph.D.
Research Team: Abdul Samad Quraishy, Naseema Quraishy, Mohammed Nader Nasiry, Seema Nasiry, Nazar Mohammed Karyar, and Abdul Aziz Yaqubi
 

A primary aim of this project was to field test a methodology for developing culturally grounded mental health assessment measures in conflict and post-conflict situations. The project combined ethnographic and multivariate methods to examine Afghan conceptions of psychological wellbeing and distress, and to develop a culturally grounded measure of mental health among Afghans. Narratives were gathered regarding 40 individuals: 10 women and 10 men who had suffered during and after the war and were continuing to experience mental health problems, and 10 women and 10 men who had also suffered but who were now doing well. From these narratives, indicators of positive and negative mental health were identified, and a 22 item questionnaire was develop assessing the frequency with which people had experienced the most commonly listed indicators of poor mental health during the previous two weeks. The survey was back-translated, pilot tested, and administered to 324 adults (162 women and 162 men) in eight districts of Kabul. The results indicated high levels of depression, anxiety, and traumatic grief among Afghan women, especially widows, and moderate levels of distress among Afghan men. The study also identified several mental health constructs that have no precise equivalent in English (i.e., in Western psychiatry), but which are quite common among Afghans. These include jigar khun, asAbi, fishar bala, and fishar payin. The scale demonstrated an excellent level of internal consistency (alpha=.93). Its construct validity was established by its strong positive correlation with a measure of war-related violence and loss, the Afghan War Experiences Scale (r=.70). An exploratory factor analysis yielded 3 factors, "Sadness with Social Withdrawal and Somatic Distress", "Ruminative Sadness Without Social Withdrawal or Somatic Distress", and "Stress-Induced Reactivity". The ASCL is currently being used in studies of Afghan mental health in Afghanistan and the United States.

A paper describing the development of the ASCL and results of the survey in Kabul is in press in the American Journal of Orthopsychiatry.  A pre-publication copy of the paper is available on request.

The Mental Health of Refugees: Ecological Approaches to Adaptation and Healing
Kenneth E. Miller and Lisa M. Rasco, Editors. Published in 2004 by Lawrence Erlbaum Associates, Inc.

This edited volume brings together experts in ecologically-based approaches to addressing the mental health needs of refugee and internally displaced communities. The opening chapter provides and theoretical and empirical basis for advocating a shift from clinic-based to community-based, ecological refugee mental health interventions. The introduction is followed by descriptions and evaluations of nine community-based mental health projects with refugee and displaced communities in a diverse range of settings, including Sri Lanka, Angola, Palestine, Cambodia, Columbia, East Timor, Guinea, and the United States (Hmong refugees in Michigan and Bosnian & Kosovar refugees in Illinois).. The book includes a chapter on the evaluation of ecological mental health and psychosocial interventions with refugees and displaced people in or near settings of ongoing conflict, and concludes with a consideration of critical issues in the development and implementation of ecological interventions with refugee and displaced populations. 

All royalties from the sales of this book are being donated to The Noor Education Center in Afghanistan, a community-based, empowerment-focused organization run by and for Afghan women.

The Mental Health of Refugees may be purchased directly from the publisher at www.erlbaum.com or at most major book retailers.

Contributors and chapters include:

Traumatic Grief Among Bosnian Refugees
Principal Investigator: Ken Miller
Research Team: Dr. Jasmina Redzic, Madhur Kulkarni, MS, Larissa Borofsky

This study is examining the prevalence and correlates of traumatic grief in a sample of 50 Bosnian refugees in Santa Clara County, in northern California. Traumatic grief is a recently identified clinical syndrome that shares symptoms with, yet is distinct from, post-traumatic stress disorder and depression. It is form of complicated grief believed to develop in some individuals in the wake of a particularly traumatic loss, either because of the nature of the loss itself, or because of the individual's attachment history and their reactions to experiences of separation and loss. Surprisingly, TG has rarely been studied among refugees, despite the frequent occurrence of the violent loss of loved ones among refugee populations.  The present study was designed to address this empirical gap.

 

The Relative Contribution of War Experiences and Exile-related Stressors to Levels of Distress Among Bosnian Refugees
Principal Investigator: Ken Miller
Research Team: Dr. Stevan Weine, Alma Ramic, Dr. Nenad Brkic, Dr. Zvezdana Djuric Bjedic, Dr. Amir Smajkic, Dr. Esad Boskailo, and Dr. Greg Worthington 

This study examined the relative contribution of war-related experiences of violence and loss, and exile-related stressors including social isolation and a lack of meaningful daily activities, to levels of trauma and depression in two groups of Bosnian refugees, one a clinical sample and the other a non-clinic, community sample. 

An article describing the study and its results was recently published in the Journal of Traumatic Stress in 2002:

Miller, K., Weine, S., Ramic, A., Brkic, N., Djuric Bjedic, Z., Smajkic, A., Boskailo,  E., & Worthington, G. (2002).  The relative contribution of  war experiences and exile-related stressors to levels of psychological distress among Bosnian refugees.  Journal of Traumatic Stress, 15, 377-387.  

ABSTRACT: 

The present study examined the relative contribution of two exile-related variables--social isolation and daily activity level--as well as war experiences of violence and loss, to levels of PTSD and depressive symptomatology in 2 groups of Bosnian refugees, one a clinical and the other a non-clinical community group.  As hypothesized, degree of exposure to war-related violence was highly predictive of level of PTSD symptoms in both groups; in addition, social isolation was significantly related to PTSD symptomatology in the community group. Also as predicted, depressive symptomatology was accounted for primarily by the exile-related stressors.  The two groups differed, however, with respect to the particular exile-related variable that was significantly associated with level of depressive symptoms. Whereas for the clinic group, level of daily activities was highly predictive of scores on the measure of depression, and social isolation was not, the reverse was true for community group. For the clinical group, which experienced a significantly greater number of interpersonal losses than the community group during the war, additional variance in depressive symptomatology was accounted for by experiences of war-related loss. Exposure to war-related violence was not associated with level of depressive symptoms in either group. Differences between groups with regard to the salience of specific stressors are considered, as are the implications of the study's findings for psychosocial interventions with refugees.

Distress and Coping Among Bosnian Refugees
Principal Investigator: Ken Miller
Research Team: Dr. Greg Worthington, Jasmina Muzurovic, JD, Susie Tipping, and Allison Goldman, BA

This study utilized semi-structured interviews to examine salient exile-related stressors as well as patterns of coping strategies and resources among a sample of 28 Bosnian refugees attending a mental health clinic in Chicago.  Preliminary results from the study were presented at the 108th annual meeting of the American Psychological Association in Washington, DC, in August, 2000. 

An article describing the study and the findings regarding exile-related stressors was published in the American Journal of Orthopsychiatry in 2002. Citation:

Miller, K., Worthington, G., Muzurovic, J., Tipping, S., & Goldman, A. Bosnian refugees and the stressors of exile: A narrative study. American Journal of Orthopsychiatry, 72, 341-354.

ABSTRACT:

This study utilized semi-structured interviews to examine exile-related stressors affecting Bosnian refugees in Chicago. Participants were 28 adult Bosnians, current or former clients in a mental health program serving the area's Bosnian refugee community. The interviews covered three areas: life in pre-war Bosnia, the journey of exile, and most centrally, life in Chicago. The use of a narrative approach allowed participants to identify and explore those exile-related stressors most salient within their community. Primary sources of exile-related distress included social isolation and the loss of community, separation from family members, the loss of important life projects, a lack of environmental mastery, poverty and related stressors such as inadequate housing, and the loss of valued social roles. The implications of the study's findings for community-based, ecological grounded interventions with refugees are considered.
 

Interpreting in Refugee Mental Health Settings
Principal Investigator: Ken Miller, Ph.D.
Research Team: Zoe Martell, MS, Linda Pazdirek, MS, Melissa Caruth, MS and Diana Lopez, BA

In this study, we examined the challenges and dynamics associated with interpreting in psychotherapy with refugees.  The methodology includes semi-structured interviews with interpreters and psychotherapists, and a questionnaire, designed for this study, assessing interpreters' experiences and perceptions regarding several variables related to the experience of interpreting in psychotherapy with refugees.  A paper based on this study was published in the American Journal of Orthopsychiatry in 2005.

Miller, K. E., Martell, Z., Pazdirek, L., Caruth, M., & Lopez, D. (2005). Interpreting in psychotherapy with refugees: An exploratory study. American Journal of Orthopsychiatry,75, 27-39
 

Growing up in Exile: A Narrative Study of Young Adult Children of Refugees
Principal Investigator: Ken Miller, Ph.D.
Research Team: Hallie Kushner, BA, Zoe Martell, MS, Jill McCall, MS, Derrick Laurel, BA

This study used semi-structured interviews to examine the unique developmental and psychosocial challenges faced by young adult children of refugees living in northern California.  Participants in this study represent a range of ethnic and national backgrounds, including Cambodian, Vietnamese,  Iranian, and Afghan.    A paper based on the study was presented at the Refugee Studies Programme at the University of Oxford in May, 2003, and a chapter based on the project is currently in press in a forthcoming edited volume on adolescents and armed conflict.