VIRTIS: An Immigrant-Driven Model for Translational Action Research in Mental Health

1. VIRTIS: An Immigrant-Driven Model for Translational Action Research in Mental Health Marius Koga, MD, MPH President, VIRTIS October 28, 2010

2. Outline • The immigrant situation in the state of California • Limitations of current Translational Action Research (TAR) model • A community-driven transnational TAR: The Veteran, Immigrant, & Refugee Trauma institute of Sacramento (VIRTIS) • Immigrants reaching out for support: UC Global Health Institute (UCGHI), Center of Expertise on Migration and Health (COEMH), Migration and Health Research Center (MAHRC)

3. A CA State immigrant problem? • With 14 million legal immigrants California (38% of total pop.) leads the nation in the number of refugees who resettle here. The collapse of the Soviet Union and of and its satellites in the Warsaw Pact, the wars in Afghanistan and Iraq, and the conditions of Iran have led to a dramatic increase of refugees from these countries. • Sacramento County, CA, the most diverse metropolitan area in the US, is home to an increasing population of Eastern European, Middle Eastern, and Central Asian immigrants with distinct languages, culture, religious, and sociopolitical experiences. • They tend to be poor, reside in highly concentrated ethnic enclaves, sense of alienation. The trauma preceding the flight is followed by the trauma of poor acculturation and alienation results in a severe loss of meaning in life.

4. The immigrant problem - Sacramento • Lack of systematic epidemiological surveys • Local systems of care based primarily on local demographics • A disparity gap between immigrant MH needs and utilization of MH services due to invisibility, lack of community empowerment, lack of advocacy, and low priority for policy makers • Resource planning with little predictive input from “upstream” • Little or no transnational partnerships

5. Disparity gap: conceptual limitations Barriers to utilization of services Overmedicalization Emphasis on patient’s need to be informed, not on a provider’s need for a comprehensive database Emphasis on “access to service” not on outreach to underserved population Disparity is seen as a gap between needs and services, not as a multilevel gap (cultural, political, financial, informational, etc). Little or no predictive studies on disparities; emphasis on crisis-driven, catching up effort Progress depends on political winds • Lack of medical insurance • Lack of transportation • Lack of culturally competent providers • Language barriers • Social stigma • no continuity of care and outreach services • Budget cuts • Political invisibility • No advocacy • Little or no information about services

6. Limitations of current Translational Action Research (TAR) model

8. Veteran, Immigrant, & Refugee Trauma Institute of Sacramento (VIRTIS) • Founding of VIRTIS as an empowering NGO bridge between communities and providers • Recruited bilingual, bicultural, professionally trained providers & researchers s • Networked with immigrant community leaders, ethnic media (radio, TV, newspapers), and local public TV KVIE • Partnered with US war veterans • An Immigrant-driven TAR www.virtis-ptsd.org

9. Mission • VIRTIS is committed to alleviate the suffering of traumatized veterans, refugees, and immigrants through direct interventions, research, collaborative projects with underserved communities, academic institutions, local and international agencies, and transnational partnerships.

10. VIRTIS has four main goals summarized in the RISE acronym: Research: advance the field of trauma studies through epidemiological surveys, qualitative studies of the individual and social psychology of violence, cultural, religious, and spiritual modulators of resilience, and outcome evaluations of transpersonal psychological interventions in vivo and in virtual reality. Integrate: key dimensions of trauma services (public health, psychosocial, transcultural psychiatry, counseling, cultural and medical anthropology, transpersonal psychology, complementary and alternative medicine, neuroscience, and virtual reality exposure therapy) in an operational model of global health. Synergize: data, vision, knowledge, problems, skills, resources, and effort with domestic and transnational partners in order to develop best practices along the migration continuum. Synergize the separate striving of veterans and refugees towards posttraumatic growth, to recognize a common ground in their humanity, experience of war trauma, and the opportunity for learning and supporting each other. Empower: refugees, immigrants, and veterans through community-based translational action research projects, education, teleinterventions, advocacy and care for victims of war, oppression, and violence so they can rise again to a healthy and meaningful functioning.

11. Organization • 2.2 million veterans call California home • over half a million of veterans with PTSD in CA • “institutionalized” by military service and traumatized by wars • Alienated upon return to their own country • Hard time reintegrating • Sacramento, the most diverse metropolitan area in the USA: over a quarter million of invisible, traumatized by war or oppression, underserved immigrants from Latin America, former Soviet Union, Eastern communist bloc, Afghanistan, Iraq, and Iran. PTSD & Alienation PTSD & Alienation

12. VIRTIS projects • Transcultural and Transpersonal Competence Education in immigrant MH for teachers, health providers, and policy makers • Partnership with CA Governor Schwarzenegger's Office of Education • Mapping of immigrant Afghan, Iranian, and Russian communities and health needs assessments • Transnational partnerships in Russia, Afghanistan, Turkey, Romania, Kyrgyzstan.

13. VIRTIS Use of Telehealth Science & Technology for immigrant MH • VIRTIS skype PTSD evals in a Turkish refugee camp in Ankara with asylum seekers from Iran. OMID Report 06/10 VIRTIS project in Kyrgyzstan supported by the Social Technologies Agency & OSCE

14. The Road Home…From Combat to College and Beyond

15. Observations • California leads the nation in number of veterans (2.2 million). The Community Colleges currently enroll 17,000 of the 22,000 veterans enrolled in higher education in the state and an estimated 8,000 to 10,000 active duty personnel, not including dependents • As of 2010, 500 veterans& dependents receiving GI Bill at Sierra College • 40% are National Guard/Reserve (CA – LARGEST in 30 Yrs)

16. Observations Continued…. • For the majority of veterans, national guard and reservist attending community colleges, this is their first real academic experience. • Every soldier's journey home is a long process affecting the lives not only of those who experience war directly, but also the families, employers, and communities they must re-connect with upon coming home.

17. The stigma associated with psychological injuries is the most serious hurdle to getting Iraq and Afghanistan veterans the mental health care they need. This carries over into the college environment , as many vets are reluctant to seek help from Disabled Student Services. Obstacles to Treatment

18. Additional Readjustment Issues and Classroom Challenges • Due to length of absence from school, majority of veterans test into remedial courses extending length of time to reach educational goals, thus using up their GI Bill • Difficulty for many veterans to fit in to classroom environment due to age difference and life experiences • Career and educational anxieties

19. Additional Readjustment Issues and Classroom Challenges • Due to length of absence from school, majority of veterans test into remedial courses extending length of time to reach educational goals, thus using up their GI Bill • Difficulty for many veterans to fit in to classroom environment due to age difference and life experiences • Career and educational anxieties

20. Additional Readjustment Issues….. • School conflicts with Guard/Reserve duties • Complexity of GI Bill Process • Difficulty juggling VA appointments with school commitments • Financial Aid (Delay in GI Bill payments; often 8 wks or more) • Lack of awareness regarding VA benefits and resources

21. How can the community & colleges best serve our student veteran population?

22. Boots to Books Community Learning Courses • 16-week semester program • (5 units) College Orientation & English writing course • Transition class for veterans. Focus on developing camaraderie, keys to success, goal setting, time management, college & community resources, combat stress, etc.

23. Veterans Division A branch of VIRTIS Veteran, Immigrant & Refugee Trauma Institute of Sacramento

24. Veteran Division Works: Development of combat related trauma research and PTSD interventions, ranging from Virtual Reality Exposure Therapy (VRET) to transpersonal psychology modalities. Provides psychosocial reintegration by offering camaraderie, recreational activities, assistance with education, financial aid employment, housing, and local resources.

25. Virtual Reality (VR) & PTSD A computer generated, ‘immersive’ (or wide field), multi-sensory information program which tracks a user in real time.

26. Virtual Iraq

27. Combat PTSD VR Elements • Multiple scenario settings • Selectable user perspective options • Create library of “trigger” stimuli • Create a highly usable “Wizard of OZ” clinician interface • Options: • Integrate scent and vibration • Integrate physiological recording into clinician interface • Main Goal: customize VR exposure based on client experience

28. HUMVEE Convoy

29. Helicopter Interior View

30. “Wizard of OZ” Clinician Interface • Scenario and settings • Location, Time of Day, Weather, etc. • User perspective • Alone, Patrol, HUMVEE, Helicopter, etc. • Real-time physiologic display • Trigger stimuli

31. Monitoring and Patient Controller

33. Military Use of PTSD VR Technology • Integrate VR combat exposure as part of a comprehensive program to assess fitness for duty • Stress inoculation training • Reintegration screening using VR PTSD with physiological recording to check for physiological reactivity • Post-combat reintegration training for military members at risk • This could provide a treatment pathway with less perceived stigma given younger military personnel’s familiarity with digital gaming • More attractive intervention than traditional talk therapy

34. VIRTIS Contribution: Cultural Anthropology & Transpersonal Psychology in VRET Cultural & spiritual dimensions of trauma: • retooling assessments (theodicy scale, Connor Davidson Resilience Scale, etc) • interventions complementing mainstream therapy and VRET

35. Next step: Use Virtual Worlds/Communities to Practice with Transnational Partners • Upstream work in Russia, Afghanistan, Kyrgyzstan, and refugee camps in Turkey • Assessment, interventions, preparedness • Get feedback from CA • Downstream work in California • Rehearse psychosocial integration of incoming immigrants • Get feedback from upstream

36. Virtual Interactive Platform for Behavioral Medicine VIRTIS Partnering with InWorld

37. What is InWorld? • InWorld is an online application using virtual environments and avatars/personalized characters, created specifically for behavioral healthcare. • Designed to be HIPAA compliant, InWorld is the first and only product to offer professionals a complete solution. • The service combines a virtual world with important functions, such as a wide range of virtual environments, customizable characters, also referred to as avatars, and the ability to input session notes. APA Conference

38. InWorld: Key Features InWorlduses flat-screen multi-user interactive virtual environments to facilitate behavioral therapy. Key features of InWorld Systems include rich real-time interaction tools such as Voice-Over Internet Protocol (VOIP) for keyboard-free interactions in any language that’s appropriate, as well as playback and imbedded assessment tools. InWorldnot only has graphic tools for rich real-time interaction, but also for dynamic after-action review (AAR). Clinicians and patients can review a session on-screen and control the viewing perspective in real-time. Additionally, there is the capability to perform in-ear coaching, where the therapist can invisibly observe real-time action and provide discrete coaching directly to the ear-set of any of the other users.

39. VR(InWorld)-Facilitated Increase Use of MH Services in CA Upstream work (Iraniansrefugees in Turkey, refugee) • Rehearse use of services in virtual CA settings • Goal: increase comfort of using service • Measure comfort level • Give feedback downstream • Monitor and adjust user immersion Downstream work (California) • Create appropriate virtual environments for upstream use • Receive feedback from upstream partner • Retool environments • Measure utilization index

40. Support for VIRTIS • VIRTIS has reached out for partnership to UCGHI Center of Expertise on Migration and Health (COEMH)and to Migration and Health research center (MAHCR) • A partnership with VIRTIS will support the work of UC researchers to compare migrant health indicators, public health policies, and policy outcomes in California with those of other U.S. regions and foreign countries.

41. Mobilization of Strategic ResourcesVIRTIS Affiliations & Partners Strategic partnerships/alliances positioning as a bridge between communities, academic, medical, research institutions, govn’t agencies, media, and policy makers • UC Davis Center for Healthcare Policy and Research (CHPR) • UC Global Health Institute • Migration & Health Research Center (MAHRC), UC Berkeley • OMID • Kyrgyz Psychiatric Association • UNHCR • Local Afghan, Iranian, Russian, Ukrainian, Bosnian, and Latino immigrant communities • American University in Central Asia (AUCA) • The Organization for Security and Co-operation in Europe (OSCE)

42. Immigrant Community-Based, Translational Action Research Projects and Interventions The Afghan and Iranian Programs The Russian and Ukrainian Program community outreach, mapping, needs assessment and radio teleintervention through Nashe Radio ( Ms. Tatiana Shevchenko, Ms. Alexandra Kirtchik; Ms. Svetlana Alshvang) • community outreach, mapping, needs assessment and telecounseling through Bamdad Persian Radio ( Mr. Mohammad Ali Golshani, Ms. Leila Farhang, Ms. Homeyra Ghaffari Soroushian)

43. Thank you! Patrick Marius Koga, MD, MPH President, VIRTIS Email: Koga@virtis-ptsd.org Catherine Morris, MA Vice-President, VIRTIS Email: Morris@virtis-ptsd.org