MENTAL HEALTH RESEARCH FOR SURVIVORS OF TORTURE AND RELATED TRAUMA

Release Date: February 5, 1998

RFA:  MH-98-012

P.T.

National Institute of Mental Health

Letter of Intent Receipt Date: March 1, 1998
Application Receipt Date: May 15, 1998

PURPOSE

This Request for Applications (RFA) seeks to encourage
investigator-initiated research to enhance the scientific
understanding of the extent and nature of torture-related mental
health problems within the U.S., and to develop and test the
effectiveness of interventions for survivors of torture.  This RFA
both extends the NIMH ongoing program of research concerning
violence and trauma, and reflects recent recommendations of
scientific advisors to NIMH in support of research on torture,
particularly focusing on epidemiology and mental health
interventions.  Participants of the 1997 conference, "Survivors of
Torture: Improving Our Understanding", specifically recommended
scientific research in the area of mental health and torture.  The
populations of concern include survivors of all ages, males and
females, and all racial and ethnic groups.  This Request for
Application addresses scientific programs on trauma, victimization,
and aggression within NIMH; coordination will be handled through
the Division of Mental Disorders, Behavioral Research, and AIDS,
National Institute of Mental Health.

Because the consequences of torture typically involve multiple
factors, applications are encouraged from a wide range of
disciplines.  Multidisciplinary applications are especially
encouraged so that a more comprehensive understanding of the role
of specific factors can be determined.  Research is strongly
encouraged on the prevalence and incidence of torture-related
mental health problems within specific regions and/or among
specific populations residing in the U.S., and on the effectiveness
of therapeutic interventions to prevent or treat the mental health
consequences of torture.  Of additional interest are applications
on the characteristics, course, and specific mental health
consequences of torture, including biological, neurological,
psychological, social, and functional factors.

Because of the recognized difficulties in conducting scientific
research with survivors of torture, and the need for strong
treatment and epidemiological research in this understudied area,
this RFA is intended to encourage researchers to overcome these
difficulties, while upholding appropriate scientific standards for
developing this knowledge base.

HEALTHY PEOPLE 2000

The Public Health Service (PHS) is committed to achieving the
health promotion and disease prevention objectives of "Healthy
People 2000," a PHS-led national activity for setting priority
areas.  This Request for Applications (RFA), is related to the
priority areas of violence, traumatic stress, abusive behavior, and
mental disorders.  Potential applicants may obtain a copy of
"Healthy People 2000" (Full Report:  Stock No. 017-001-00474-0 or
Summary Report: Stock No. 017-001-00473-1) through the
Superintendent of Documents, Government Printing Office,
Washington, DC 20402-9325 (telephone 202-512-1800).

ELIGIBILITY REQUIREMENTS

Applications may be submitted by domestic and foreign,   for-profit
and non-profit organizations, public and private, such as
universities, colleges, hospitals, laboratories, units of State and
local governments, and eligible agencies of the Federal government. 
Racial/ethnic minority individuals, women, and persons with
disabilities are encouraged to apply as Principal Investigators. 
Applications for small grants will only be accepted from domestic
institutions.

MECHANISM OF SUPPORT

This RFA will use the National Institutes of Health (NIH) research
project grant (R01), small grant (R03), Exploratory/Developmental
Grants for Psychosocial Treatment Research (R21), and the
Collaborative R01s for Clinical Studies of Mental Disorders
mechanisms.  Responsibility for the planning, direction, and
execution of the proposed project will be solely that of the
applicant. The total project period for an application submitted in
response to this RFA should not exceed five years.  The anticipated
award date is September, 1998.  Because the nature and scope of the
research proposed in response to this RFA may vary, it is
anticipated that the size of an award will vary also.  Because each
of these mechanisms has special eligibility requirements,
application formats, and review criteria, applicants are strongly
encouraged to consult with program staff (listed under INQUIRIES)
and to obtain appropriate additional information regarding
mechanisms.

This RFA is a one-time solicitation, although research applications
on torture, aggression, trauma, and victimization are encouraged on
an ongoing basis at NIMH.  Future competing continuation
applications or other unsolicited applications on torture or
related topics will compete with all investigator-initiated
applications and be reviewed according to the customary peer review
procedures.

FUNDS AVAILABLE

For FY 1998, it is estimated that up to $1.2 million will be
available for approximately 4-8 awards. Support may be requested
for a period of up to 5 years, although some mechanisms have
restrictions regarding the maximum period of support.  Grant funds
may not be used to operate a treatment, rehabilitation, or other
service program; however, if treatment costs are requested in
association with the research protocol, detailed information on any
hospitals, clinics, or providers and the amounts requested will be
required (see instructions for PHS Form 398).  Prospective
applicants are strongly encouraged to contact NIMH staff (listed
under INQUIRIES), in order to ascertain any dollar limitations
associated with specific program mechanisms.

RESEARCH OBJECTIVES

Background

The mental health consequences of violence and traumatic stress
worldwide have emerged as one of the major public health problems
of our time.  While it is difficult to estimate accurately the
prevalence of violence and traumatic stress events because of
variations in the nature and definitions of these problems, it is
clear that a sizeable portion of the world's population are exposed
to violent and traumatic experiences, including torture.  Further,
because of the many life circumstances associated with torture-
related violence and trauma, including ethnopolitical warfare,
forced relocation, violent crime, and political oppression, it is
likely that the severe health and mental health consequences
associated with such violence and trauma will continue to be a
major public health problem.  The consequences of violence and
torture affect not only individuals and families, but also
communities, societies, and entire nations.  The legacy of these
experiences -- because of the indelible marks they leave -- often
continue into subsequent generations creating an enduring cycle of
pain and suffering.  Torture constitutes one of the most extreme
forms of trauma, potentially resulting in long-term psychological
and physical suffering.

For the purposes of this document, it should be noted that the term
"torture" has been defined in different ways by different
organizations, and for different purposes.  The two most commonly
used definitions of torture were formulated by the World Medical
Association and by the United Nations.  The World Medical
Association's definition was developed in 1975; it is frequently
called the "Declaration of Tokyo," and it represents a popular
definition among the medical community where it governs
professional standards and ethics.  The "Declaration of Tokyo"
defines "torture" as:

". . . the deliberate, systematic, or wanton infliction of physical
or mental suffering by one or more persons acting alone or on the
orders of any authority, to force another person to yield
information, to make a confession, or for any other reason."

In contrast to the World Medical Association definition, the United
Nations definition of "torture" delineates the legal and political
responsibilities of governments.  It states:      
". . .For the purpose of this Convention, the term "torture" means
any act by which pain or suffering, whether physical or mental, is
intentionally inflicted on a person for such purposes as obtaining
from him or a third person, information or a confession, punishing
him for an act he or a third person has committed or is suspected
of having committed, or intimidating or coercing him or a third
person for any reason based on discrimination of any kind, when
such pain or suffering is inflicted by or at the instigation of or
with the consent or acquiescence of a public official or other
person acting in an official capacity.  It does not include pain or
suffering arising only from, inherent in or incidental to lawful
sanctions."

It should be emphasized that, for the purposes of this RFA, it is
recognized that the experience of torture may extend beyond these
legal or statutory definitions to include specific characteristics
of torture as documented in personal testimony or in clinical,
medical, or legal settings.

Little is known about the extent of torture and the nature of the
torture-related problems among individuals throughout the world,
including those now residing within the U.S.  Epidemiological
studies are often very difficult because of the psychologically and
politically sensitive nature of the issue.  The most reliable data
available are those published by human rights organizations such as
Amnesty International (AI). Although AI figures represent a
fraction of all human rights abuses in the world, they provide an
estimate about the extent of the problem; recent reports cite over
150 countries for some form of human rights violation in a   one-
year period.

In 1991, systematic torture was reported in 93 of the 204
countries. Reports of torture were more common from regions
affected by political unrest, including mass demonstrations, riots,
outbreaks of violence, killings, coup attempts, civil war,
separatist or guerilla groups, armed tribal conflict, rebellions,
and conflicts with various opposition groups demanding social and
political reform. The problem was not confined to these regions,
however, as systematic torture and/or severe ill treatment were
also reported in 25% of the western European and North American
countries.  At the present time, only rough estimates are available
regarding the prevalence of torture among various at risk
populations.  Of the world's 14 million refugees, between 5% and
35% (i.e., 700,000 to 4.9 million refugees) are estimated to have
had at least one experience of torture.  These figures do not
reflect the experiences of non-refugee populations, nor the current
extent of the problem after the recent developments in eastern
Europe, former Yugoslavia, Middle East, and other parts of the
world torn by political turmoil, nationalistic movements, and
regional wars.  More systematic research establishing the scope of
this problem is needed.

Researchers and clinicians have also begun to acknowledge that the
destructive medical, psychiatric, and existential consequences
associated with the experience of "torture" and related trauma may
extend beyond the victim to include family members, the
perpetrator, the healer, and society.  Certain population sectors
are particularly vulnerable to the victimization associated with
torture, including refugees, war veterans, political dissidents,
ethnic and religious minorities, women, children, and the elderly. 
For these groups, exposure to violence and trauma, including
torture, is often a central part of their lives.  This RFA, which
focuses on torture experiences, recognizes that torture may have
been an experience of many groups residing in the U.S., including
refugees, asylees, immigrants, other displaced persons, and U.S.
citizens who were tortured abroad, and more research is needed that
more fully documents the extent, nature, and consequences of these
experiences.

Additionally, although effective treatments are being developed for
survivors of other forms of violence and trauma, much more research
is needed on the specific characteristics and needs of survivors of
torture, and the development and testing of different kinds of
interventions. From a limited number of studies across various
cultures, it is clear now that survivors of torture can experience
severe mental health problems in the aftermath of torture.  These
symptoms include re-experiencing, hyper-arousal, avoidance
behavior, amnesic episodes, difficulty concentrating, and poor
memory.  Physical consequences of politically-motivated or
government sanctioned torture are extensive and severe.  Specific
neuropsychological symptoms are often difficult to diagnosis
because of additional head injuries, the multiplicity of symptoms,
and co-morbidity.  Post-traumatic stress disorder (PTSD) is a
common diagnosis among survivors of torture, as are major
depression, substance abuse, and other anxiety disorders.  Much
more research is needed to specifically examine the cultural and
clinical appropriateness of the PTSD and other psychiatric
diagnoses with survivors of torture, and to more fully examine
changes in function, disability, subjective distress, and
resilience, and the implication of these changes for the
development of appropriate treatment programs.

Through this announcement, studies on torture are encouraged that
will address critical gaps in knowledge concerning the accurate
measurement of the scope and impact of torture and related trauma
among individuals residing in specified U.S. regions, and on the
effectiveness of research-based intervention studies for the
purposes of understanding and improving the quality of mental
health care to torture survivors.  Research supported in this
program will also include studies of the role of formal mental
health services, informal support networks, and coping and
resiliency factors as mediators of the effects of torture, as
factors investigated within the context of epidemiological or
treatment studies.

Listed below are examples of research projects that could advance
scientific knowledge on the effects of torture.  The list is not
exhaustive, and it is expected that additional important research
topics may be identified by those who respond to the announcement. 
Studies in these areas can include, but are not limited to:

o  Studies of the prevalence of torture experiences and torture-
related mental health problems among individuals residing in
specified regions in the U.S. (including refugees, asylees,
immigrants, and U.S. citizens).  If appropriate, multi-site studies
may be proposed.  Proposed studies may utilize a variety of
epidemiological and other methodologies, including key informant
surveys, individual interviews with survivors, record reviews,
etc., and should be carefully designed to obtain valid and reliable
information.

o  Studies of specific populations (e.g., key informants, specific
cultural or ethnic groups, children, witnesses to torture, family
members) to determine similarities and differences within and
across groups in terms of their rates of exposure to different
types of torture or related trauma, the mental health and
functional consequences of this exposure, and their experiences
with mental health services and treatment.

o  Studies testing the efficacy and refinement of individual,
family, and/or community-level models and methods of intervention
for survivors of torture (e.g., pharmacological and other medical
treatments, psychosocial methods, family support and crisis
intervention programs, home visitation programs, psychiatric and
social service placements, mentoring programs, and community-based
efforts).

o  Studies that apply established or new intervention strategies
for preventing the onset of mental health problems, including
strategies for reducing severity, preventing recurrent or relapse,
preventing functional impairment, or maintaining healthy or
effective functioning.

o  Studies of the effectiveness of interventions for survivors of
torture in various medical, social, and community settings,
including the use of conceptually sound intervention models with
various social and cultural groups. Such intervention studies may
also include studies of factors that modify symptom severity or
dysfunction resulting from exposure to torture (e.g., individual
strength and resilience factors, response of significant others,
social support, community and service sector response).

o  Research on appropriate methodologies and/or techniques required
to advance research in the understanding of the effects of torture,
including the development of assessment and screening instruments
to guide treatment and research with survivors of torture, and the
development of new manuals to guide treatment practitioners.

o  Development of innovative, effective, and ethical methods to
obtain, maintain, and support the research participation of
survivors of torture.

o  Studies evaluating mental health treatment modes designed to
avoid burnout or other psychological disturbance among mental
health providers working with survivors of torture.

Research Plan

Proposed studies should be based on a strong conceptual framework,
drawing on existing empirical literature and relevant theory, for
both the selection of the research components and the specific
research hypotheses.  The design should include control or
comparison groups as needed, and the data should be collected,
analyzed, and interpreted in such a manner that scientifically
valid inferences about the research results can be drawn.  In
addition, it is suggested that the following considerations be
addressed in the preparation of an application:

o  Applicants should propose the most rigorous research design
possible as appropriate to the proposed study.

o  The selection of each component of the study should reflect
existing research findings and have a strong conceptual foundation,
but may also include new theory-driven or research-based
components, which focus on variables identified in basic studies as
potentially important to mental health following exposure to
trauma.

o  Applicants proposing intervention studies should offer a
standardized intervention package, so as to permit reliable
implementation and potential replication.  Proposals may also focus
on the development of intervention manuals that clearly describe
the content and procedures for all intervention components.

o  Feasibility issues should be clearly addressed in detail. Plans
for implementation of the research should include procedures for
obtaining and maintaining the necessary community relations,
training and supervising project staff, insuring implementation
fidelity, securing ongoing access to the participants, recruiting
a representative sample of the target population, recruiting
appropriate staff for the research intervention, and monitoring
subject participation over time.

o  Applicants should document the commitment, support, cooperation,
and nature of the proposed collaboration of community agencies or
other entities or settings outside the applicant organization whose
support is essential for the conduct of the research.  For example,
a university-based project could demonstrate a working relationship
with existing community service projects, which provide services to
survivors of torture.

o  Special attention should be directed toward the unique needs and
special concerns of survivors of torture, including those of
specific cultural, racial, and ethnic group members, so that
services and opportunities are appropriate and acceptable to these
individuals (where feasible and appropriate to the study question). 
Issues of potential for retraumatization and confidentiality should
be fully addressed in the application.

o  Validity and reliability are fundamental to all research, but
particularly important in research with torture survivors where
many factors challenge the collection of valid and reliable
information. Information collected must be viewed with appropriate
consideration of issues of culture, politics, language, fear of
retribution to self or others, and re-traumatization
symptomatology.  The torture survivor may possess fear and distrust
of authorities, expectations that the assessment will assist (or
harm) their plight, and the experience distress of re-telling their
experiences.  Furthermore, survivors are likely to have concerns
about confidentiality, especially if they are involved in legal
procedures involving requests for asylum. These issues should be
fully addressed in the application.

o  Cultural and language issues are particularly significant in
research with survivors of tortures and special consideration must
extend beyond mere linguistic translation to issues of construct,
scale, and normative equivalencies. This includes attention to
potential differences in cultural expression of torture-related
symptoms across populations, and other contextual factors that
contribute to differences in mental health and functional
consequences of exposure to torture.

Community Involvement

In any traumatic stress research conducted in communities, the
community itself may be an important source of innovative ideas for
addressing sensitive social problems.  Researchers should have the
cooperation and participation of those who are the focus of their
work.  Working with a researcher or a community service agency that
is viewed as an integral part of the community and is well
respected in the community may greatly enhance the quality of the
research study.  As appropriate, community representatives may be
given a voice in choosing research topics, collecting data, or
interpreting results, among other possibilities.  Community input
may be most meaningful if it is built into the research process
from the beginning.  Basing the research project in the community
being studied is a positive first step.

INCLUSION OF WOMEN AND MINORITIES IN RESEARCH INVOLVING HUMAN
SUBJECTS

It is the policy of the NIH that women and members of minority
groups and their subpopulations must be included in all NIH
supported biomedical and behavioral research projects involving
human subjects, unless a clear and compelling rationale and
justification is provided that inclusion is inappropriate with
respect to the health of the subjects or the purpose of the
research. This new policy results from the NIH Revitalization Act
of 1993 (Section 492B of Public Law 103-43).

All investigators proposing research involving human subjects
should read the "NIH Guidelines For Inclusion of Women and
Minorities as Subjects in Clinical Research," which have been
published in the Federal Register of March 28, 1994 (FR 59
14508-14513) and in the NIH Guide for Grants and Contracts, Volume
23, Number 11, March 18, 1994.

Investigators also may obtain copies of the policy from the program
staff listed under INQUIRIES.  Program staff may also provide
additional relevant information concerning the policy.

LETTER OF INTENT

Prospective applicants are asked to submit, by March 1, 1998, a
letter of intent that includes a descriptive title of the proposed
research, the name, address, and telephone number of the Principal
Investigator, the identities of other key personnel and
participating institutions, and the number and title of this RFA. 
Such letters are requested only for the purpose of facilitating
technical assistance and review by providing an indication of the
number and scope of applications to be received.  Although a letter
of intent is not required, is not binding, and does not enter into
the review of a subsequent application, the information that it
contains allows NIMH staff to estimate the potential review
workload and avoid conflict of interest in the review.

The letter of intent is to be sent to:

Farris Tuma, Sc.D.
Division of Mental Disorders, Behavior, and AIDS Research
National Institute of Mental Health
Parklawn Building, Room 18C-14
Rockville, MD  20857
Telephone:  (301) 443-3728
FAX:  (301) 443-4611

APPLICATION PROCEDURES

The research grant application form PHS 398 (rev. 5/95) is to be
used in applying for these grants.  These forms are available at
most institutional offices of sponsored research and from the
Division of Extramural Outreach and Information Resources, National
Institutes of Health, 6701 Rockledge Drive, MSC 7910, Bethesda, MD
20892-7910; telephone (301) 710-0267; fax (301) 480-0525; Email:
ASKNIH@OD.NIH.GOV.

The RFA label available in the PHS 398 (rev. 5/95) application form
must be affixed to the bottom of the face page of the application. 
Failure to use this label could result in delayed processing of the
application such that it may not reach the review committee in time
for review.  In addition, the RFA title and number (Mental Health
Research for Survivors of Torture and Related Trauma, MH-98-012)
must be typed in section 2 of the face page of the application form
and the YES box must be marked.

Submit a signed, typewritten original of the application, including
the Checklist, and three signed, photocopies, in one package to:

CENTER FOR SCIENTIFIC REVIEW
NATIONAL INSTITUTES OF HEALTH
6701 ROCKLEDGE DRIVE, ROOM 1040 - MSC 7710
BETHESDA, MD  20892-7710
BETHESDA, MD  20817 (for courier/overnight mail service)

At the time of submission, two additional copies of the application
must be sent to:

Farris Tuma, Sc.D.
Division of Mental Disorders, Behavior, and AIDS Research
National Institute of Mental Health
Parklawn Building, Room 18C-14
Bethesda, MD  20857

Applications must be received by May 15, 1998.  If an application
is received after that date, it will be returned to the applicant
without review.  The Center for Scientific Review (CSR) will not
accept any application in response to this RFA that is essentially
the same as one currently pending initial review, unless the
applicant withdraws the pending application.  The CSR will not
accept any application that is essentially the same as one already
reviewed.  This does not preclude the submission of substantial
revisions of applications already reviewed, but such applications
must include an introduction addressing the previous critique.

REVIEW CONSIDERATIONS

Upon receipt, applications will be reviewed for completeness by the
CSR and for responsiveness by NIMH staff.  Incomplete and/or non-
responsive applications will be returned to the applicant without
further consideration.  Applications that are complete and
responsive to the RFA will be evaluated for scientific and
technical merit by a peer review group convened by the NIMH in
accordance with the review criteria stated below.  As part of the
initial merit review, all applications will receive a written
critique and may undergo a process in which only those applications
deemed to have the highest scientific merit will be discussed,
assigned a priority score, and receive a second level review by the
appropriate national advisory council or board, when applicable.

Review Criteria

o  scientific, technical, or medical significance and originality
of proposed research;

o  appropriateness and adequacy of the experimental approach and
methodology proposed to carry out the research;

o  qualifications and research experience of the Principal
Investigator and staff, particularly, but not exclusively, in the
area of the proposed research;

o  availability of the resources necessary to perform the research;

o  appropriateness of the proposed budget and duration in relation
to the proposed research;

o  adequacy of plans to include both genders and minorities and
their subgroups as appropriate for the scientific goals of the
research.  Plans for the recruitment and retention of subjects will
also be evaluated;

o  adequacy of plans to ensure protections to the concerns of the
survivors of torture regarding issues of confidentiality and re-
traumatization;

o  adequacy of plans to ensure that informed consent procedures are
to be strictly followed.  The research participants must be fully
informed regarding the purposes and potential uses of the research,
and the possible positive or negative effects.  Participants must
be informed of their freedom to refrain from answering any or all
questions, and every effort must be made to be sure that the
participants understand all aspects of the assessment activities,
and that efforts to ensure confidentiality are fully addressed.

The initial review group will also examine the provisions for the
protection of human and animal subjects, the safety of the research
environment, and conformance with the NIH Guidelines for the
Inclusion of Women and Minorities as Subjects in Clinical Research.

AWARD CRITERIA

Availability of funds, and scientific merit as determined by peer
review and programmatic priorities, will be the primary criteria
for award determination. Only applications judged to have the
highest scientific standards of excellence will be considered for
award.

INQUIRIES

Inquiries concerning this RFA are encouraged.  The opportunity to
clarify any issues or questions from potential applicants is
welcome.

Direct inquiries regarding programmatic issues to:

Farris Tuma, Sc.D.
Division of Mental Disorders, Behavior, and AIDS Research
National Institute of Mental Health
Parklawn Building, Room 18C-14
Rockville, MD  20857
Telephone:  (301) 443-3728
FAX:  (301) 443-4611
Email:  ftuma@nih.gov

Kenneth Lutterman, Ph.D.
Division of Services and Intervention Research
National Institute of Mental Health
Parklawn Building, Room
Rockville, MD  20857
Telephone:  (301) 443-3373
FAX:  (301) 443-1726
Email:  klutterm@nih.gov

Direct inquiries regarding fiscal matters to:

Diana S. Trunnell
Grants Management Branch
National Institute of Mental Health
Parklawn Building, Room 7C-08
Rockville, MD  20857
Telephone: (301) 443-2805
FAX:  (301) 443-6885
Email:  Diana_Trunnell@nih.gov

AUTHORITY AND REGULATIONS

This program is described in the Catalog of Federal Domestic
Assistance No. 93.242 (Mental Health Research Grants).  Awards are
made under authorization of the Public Health Service Act, Title
IV, Part A (Public Law 78-410, as amended by Public Law 99-158, 42
USC 241 and 285) and administered under PHS grants policies and
Federal Regulations 42 CFR 52 and 45 CFR Part 74.  This program is
not subject to the intergovernmental review requirements of
Executive Order 12372 or Health Systems Agency review.  Awards will
be administered under PHS grants policy as stated in the Public
Health Service Grants Policy Statement (April 1, 1994).

PHS strongly encourages all grant and contract recipients to
provide a smoke-free workplace and promote the nonuse of all
tobacco products.  In addition, Public Law 103-227, the  Pro-
Children Act of 1994, prohibits smoking in certain facilities (or
in some cases, any portion of a facility) in which regular or
routine education, library, day care, health care or early
childhood development services are provided to children.  This is
consistent with the PHS mission to protect and advance the physical
and mental health of the American people.

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