‘You know the most important thing if you are taking care of someone is to give someone hope… What I went through, it was for the benefit of the community. So I carry what I went through to help this one… that is why we want to introduce courses whereby some of them who were abducted can do a course, to do a profession, to have something for the survival for your family.’
Mary (a pseudonym) is 37, which makes her an ‘elder’ in her community. She is a survivor of the 23 years of brutal internal strife, abduction, killing and rape unleashed in Northern Uganda in the mid-1980s by Joseph Kony’s Lord’s Resistance Army (LRA). Some 25,000 children were abducted during the conflict. Boys were forced to become child soldiers and terrorised into committing terrible atrocities on their own families and communities; girls were raped and killed or forced to become wives of LRA commanders. The civilian population was caught between the LRA fighters and the government forces; some two million people fled their homes to overcrowded IDP (internally displaced people) camps that became, effectively, open prisons, their inhabitants too scared to leave lest they be killed or abducted.
Mary is a peer counsellor trained through a Western humanitarian aid programme to provide group and one-to-one psychosocial support to the people in her community, many of whom are still suffering post-traumatic stress from the toxic legacy of the war and the horrors they experienced and witnessed. She is one of six psychosocial support workers interviewed by counselling psychologist Claire Marshall for her doctoral thesis. Marshall believes psychologists could and should be doing much more to contribute to humanitarian interventions in low- and medium-income countries (LMICs) torn apart by civil war, invasion and natural disasters. Her study sought to explore what people delivering psychosocial support felt about it, how useful it really was and how relevant it was to their cultural context and environment.
There is certainly a need. A recent WHO study of 21 LMIC countries found widespread psychological trauma: more than 10 per cent of people reported witnessing or personally experiencing violence, accidents, exposure to war, or trauma to a loved one. Some 3.6 per cent of the world’s population suffers post-traumatic stress disorder (PTSD) in any one year, the same study showed.
But research into the benefits and outcomes of psychosocial humanitarian interventions is rare. International guidelines on how to address mental health needs in humanitarian aid packages have only been available since 2007, when the IASC (Inter-Agency Standing Committee) consensus Guidelines on Mental Health and Psychosocial Support in Emergency Settings were produced by a coalition of aid agencies. In July this year WHO published guidelines specifically on The Management of Conditions Specific to Stress. Says Mark Jordans, Head of Research at the Dutch aid agency HealthNet TPO: ‘Psychosocial care is in the system now. Most acknowledge that it should be an integral part of any aid package. But the research into what works is marginal compared with high-income countries, of course. There are some reviews and summaries of evaluations but not a lot and there is a lot to be done.’
Network for Africa (N4A) is a UK-based charity that works with post-conflict communities in Rwanda and Uganda, providing training to local people to deliver psychosocial support to their peers. In Uganda, their work has been focused on Patongo, a camp for IDPs in the north, near the border with Sudan. Once a small farming community of 6,000 people, it had become home to some 65,000 Ugandans by the time the war ended in 2006, when the camp was closed and people began to drift back to their homelands or were encouraged to move to the satellite villages being established locally. With a population of around 28,000, it is now the administrative centre for the district.
Some 83 per cent of the people in Patongo witnessed torture; 73 per cent witnessed killings. Some were away from their homes and families for 10–15 years. When they came back they might be ostracised by their community. Women might have returned with a child fathered by an LRA fighter. The men still feel ashamed and guilty about the terrible things they were forced to do by the LRA; suicide rates are high. ‘They feel alone and can’t connect with anyone. They don’t understand why this has happened to them and their emotions are bottled up. This has led to a lot of problems with alcohol. Partly it’s because the men have nothing to do. The women do it all. But, when you ask them, they say they drink so heavily because they want to forget,’ says Sophie McCann, N4A Executive Director. ‘Network for Africa tries to get to places where humanitarian aid has pulled out and development aid has come in, where there is often a gap. There is increasing awareness in the humanitarian aid community that trauma counselling and psychosocial support are needed but it is very underfunded and also it’s not seen as a priority, partly because mental health problems are often difficult to identify and the benefits of counselling can be quite hard to record. So the emphasis is on rebuilding houses and schools, providing water, health facilities. But the invisible health needs are neglected. We focus on psychosocial support and unlocking people from the paralysis that trauma can cause.’
Barbara Bauer, a US psychologist, first came to Patongo with her colleague, counsellor Shelly Evans, to offer psychosocial training in 2008. They had previously worked in Rwanda and brought to Patongo the model of peer counselling that they developed with the displaced and traumatised people there. ‘We started by teaching them simple trauma interventions: listening skills, relaxation techniques, how to hear people and let them talk about their experiences, the use of imagery, some techniques for helping to contain nightmares. We said we would train 40 people and 40 people came, then 50, then 65… We had people lining the walls; it was overwhelming. So we decided instead to select a smaller number to be our advance group,’ Barbara says.
It is this group of 26 people, equal numbers of men and women and representing younger and ‘elder’ age groups, that still delivers psychosocial support across Patongo and its satellite villages. But what they offer has evolved far beyond the trauma counselling brief.
Barbara and Shelly return regularly to Patongo, for several weeks twice a year, to help the psychosocial workers update and extend their skills. In November they will make their 10th visit. First they added training in leadership skills, then conflict resolution, because land disputes have become a major source of contention as people return to their homes to find natural boundary markers and local knowledge have been wiped out. Then they addressed domestic violence, and gender-based violence more broadly – both major problems in Patongo. An even greater problem is alcohol – Uganda has the highest per capita consumption of alcohol in the world, and in Patongo it has the additional deadly effect of making people blind due to contamination from the metal containers in which the alcohol is brewed. Drug abuse is also common. As elsewhere in Africa, there’s widespread HIV and AIDS, and the counsellors needed to know both how to educate people about prevention and also to ensure they continued to take their medication. Family planning was another important issue in an area where polygamy is common and men may have two or three wives and 12+ children.
‘Our initial reaction as therapists was initially to be overwhelmed by the scale of the problems. We didn’t know where to start. Do you deal with the domestic violence? But then you had to deal with the alcohol, and if you want to deal with the alcohol you had to address the trauma too. Everything is interlaced,’ says Barbara.
‘Every time we go we meet with the counsellors and continue their training. In the interim, we have set up peer supervision and they meet together to talk through the issues and problems they are facing. All our training materials have been written and translated into the local language, and they do additional training among themselves, reviewing what we teach them when we come. We have a unit on “Helping the Helpers” and how you avoid getting overwhelmed. All our counsellors are paid. It’s a small stipend but to have any income at all is a good thing in Patongo.’
The counsellors mainly work in pairs, one male and one female, bicycling out to the villages to run groups of up to 30 people. They also offer one-to-one counselling and advice if needed, on a huge range of practical, social and psychosocial issues. Sophie McCann says they are currently seeing some 840 people through the groupwork and over 1,000 people have received individual counselling in the past six months. ‘We’ve also been doing advocacy radio broadcasts to encourage people to access the counselling centre and to raise awareness of what trauma and counselling are.’
In 2010, with the support of N4A, the counsellors formed themselves into the Patongo Counselling Community Outreach (PCCO) and opened a counselling centre in ‘downtown’ Patongo, where people can come for individual counselling. ‘My thought was that no one would come because no one would know what it was all about but, as our counsellors go out to the villages and the word spreads that they really can help, people are coming into the centre and asking to speak to a counsellor. It’s really catching on,’ says Barbara.
Rebuilding the community
Claire Marshall’s interviewees had a very clear understanding of the problems afflicting ravaged, displaced communities like their own, their origins and the need for people to rebuild a sense of community and autonomy, to move on from dependency on outside aid organisations.
They had ideas too about how to address the problems using methods very like Western psycho-education and groupwork techniques. The psychosocial support should be delivered by local people, trained by ‘experts’ like Barbara, Mary argued; it was important that communities should not be reliant on Western counsellors parachuted in. Ocan, a 27-year-old man, talked about traditional ways of rebuilding community resilience using dance, drama, song and spiritual faith: ‘… resurrection of the cultural gathering… traditional dance... When this kind of dance is organised I think even the children will learn about the culture. Unity will come in. Socialisation will also develop. People will feel that they are really busy, they are committed, instead of one being idle or being isolated, thinking about something that has happened to his or her life,’ he said. But it would take time: ‘It is not an easy task. You cannot get finished tomorrow.’
Mary wished the support had been available sooner, when the people first came to the camps: ‘...the culture had really been destroyed when we were in the camp… Respect for our parents was lost… Your father is so drunk here and talking abusive words… Fathers started sleeping with their daughters, their relatives, incest – something that was not happening previously in our villages… everything was changed,’ she said. ‘Of course the teaching of hygiene promotion was there – “Keep your toilet clean, keep your house”… there was anger, domestic violence, people would fight, you know, all these things. If there was counselling going on, a group counselling within the camp… but there was nothing like that.’
Interviewees described the steps being taken already to rebuild their community. One woman, Ayaa, had set up an orphanage: ‘These children are the future generation… I want to help this generation,’ she told Marshall.
David described how the women in his community have formed small self-help groups that provide both emotional and practical support: ‘… they are being counselled together and then they are also being taught to save money whereby every Sunday, at least one day in the week, they would be saving money… So the women have become very, very responsible.’
‘We know what works from our research in the West but we have to be open to the fact that this is a completely different context,’ Marshall says. ‘My sense from the interviews is that they needed to restore their community narrative and they needed to do it in their own way. If we do not respect and work with that, our interventions risk becoming another imposition packaged up as charity.’
Sophie McCann at N4A echoes this understanding: ‘People’s traditional coping strategies have been completely lost in the camps. Families have been split up, elders have been killed. The knowledge that would have been passed down from generation to generation has been lost. So when people say we are imposing Western ways of coping with problems, we argue that we are tapping into something that had existed but has been erased by war and genocide. These communities have always had their wise women, their elders who meted out advice and justice in disputes; it happens in all countries and communities; what varies is how formal and structured it is.’
‘In Patongo we haven’t found anyone who isn’t appreciative of what we are doing,’ says Barbara. ‘We’ve had numerous requests from other villages wanting counsellors and training because they have seen the difference it makes. They hear that so-and-so was suicidal and they saw a counsellor and they are still alive and they want some of that too. The counsellors are telling us that they are using what we have taught them and that they are working with returning soldiers and young mothers and having some pretty good successes with it.’
What works when
N4A is now turning its attention to poverty, another legacy of trauma and the war. It has been helping the Patongo counselling groups to set up group savings and loans schemes; the peer counsellors have been trained to support small income-generating projects; a project to support people living with HIV to run a small dairy farm is under development and N4A is exploring microfinance schemes to help women set up agricultural enterprises.
‘Addressing trauma through psychosocial interventions has started the process of regenerating the community,’ Barbara Bauer argues. ‘When I was with Medécins Sans Frontières in Nepal doing similar work with traumatised women, we found they were much better able to take advantage of the vocational skills training, microfinance and other programmes if their trauma was addressed first.’
That people traumatised by war and sexual violence may first need help with the psychological effects before they can start to rebuild their lives makes intuitive sense. A recently published study of a programme in Democratic Republic of Congo provides convincing evidence of the benefits.1 The study was conducted by researchers from the Johns Hopkins Bloomberg School of Public Health and the University of Washington with the International Rescue Committee. It compared two groups of women drawn from several villages in eastern Congo. Half were offered a 12-week programme of cognitive reprocessing therapy (CPT) and half received individual psychosocial support, both delivered by trained local ‘paraprofessionals’. Just over half the 400 women in the study completed the programme. Both groups benefited from the interventions but the women who received the CPT benefited much more: six months post-intervention only nine per cent of the CPT group still had symptoms of anxiety, depression or PTSD, compared with 42 per cent of those who received individual support. The researchers say that this demonstrates that interventions developed in the West to help traumatised people are equally effective in low-income countries with little access to qualified mental health professionals.
HealthNet TPO has amassed a large body of research on the effectiveness of humanitarian psychosocial interventions in LMICs from its involvement in projects in both Africa and Asia. Mark Jordans says their evidence supports a different approach: that trauma may not necessarily be the priority in a humanitarian emergency. ‘There has been a lot of focus on trauma interventions and they have been found effective to reduce traumatic stress symptoms, but the question not sufficiently asked is whether trauma and PTSD are the chief complaints we should be targeting, and at this point we think they are not,’ he argues.
He is emphatic that people’s trauma does need to be addressed. ‘We do need to be sensitive to the trauma and respond to possible PTSD problems but we find that trauma-related problems are only a small part of the difficulties people are suffering from. The latest research is showing that the negative impact of traumatic events on the mental health of people in an emergency situation is to a large degree mediated by daily stressors. If you ask people post-emergency what are their biggest concerns, it is dealing with daily stresses and hassles, including poverty or ongoing conflict or divisions in the community.’
These are the issues with which the people involved want help. ‘So far, we have been unable sufficiently to address how to tackle these social components, how to deal with whole communities that have been devastated. It is often easier to target individual problems within the community,’ Jordans believes. This is now an important focus of HealthNet TPO’s development work – a ‘community systems strengths approach’ that integrates community resilience-building with other humanitarian initiatives and programmes. ‘We are looking at ways to help communities rebuild community efficacy so they can take actions to address their social problems, because outside agencies should not and cannot address all these issues for them; our role is maybe to start the process,’ says Jordans.
Mental health gap
Another important finding emerging from HealthNet TPO’s work is that, while what they call para-professional counsellors – well-trained, well-supported local people delivering psychosocial interventions – are effective in tackling some of the mental health problems in these communities, they are not enough on their own. People have been suffering severe mental illness before the conflict, and continue to do so afterwards. To address WHO’s ‘mental health gap’, what is needed is a ‘multi-layered’ system, covering the range of needs from health education and resilience building through family interventions, individual counselling and psychosocial support to medical care and treatment for children and adults with severe mental illness. And these systems of mental health care need to be embedded in the country’s own health care structures, to ensure sustainability. But with most LMIC countries able only to invest a tiny proportion of their public spending on health (let alone mental health), establishing such systems remains a major challenge. WHO has been seeking to address this through its Mental Health Gap Action Plan, first launched in 2008.
Another UK-based charity, BasicNeeds, has developed a model based on community development principles in a bid to fill this gap. It runs what we in the West would call peer support and recovery programmes, working with and through local partners and government organisations in 13 LMICs worldwide. BasicNeeds is concerned primarily with supporting people with mental illness or epilepsy in the world’s poorest countries where there are few if any psychiatric resources. Its founder and director Chris Underhill has a background in a farming, agricultural development and social entrepreneurship, which is reflected in the organisation’s model of intervention.
This has five ‘modules’: capacity building, community mental health, livelihoods, research and collaboration. It aims, put very simply, to ensure people with a mental illness or epilepsy are able to get a diagnosis, begin treatment, join a self-help support group and become well enough to undertake some kind of work to generate their own income and become part of their local community.
In the countries where BasicNeeds works, there may be just one psychiatrist for every one and a half to two million people. Volunteers do much of the work of identifying people who might need their help and supporting them to access treatment and move on towards recovery. With such a paucity of formal psychiatric resources, Underhill says the notion that they are exporting a Western medical model is laughable. ‘For most people, attendance at a clinic is only a small part of their monthly activities. Much of the work that BasicNeeds encourages is related to economic and social activity, self-help and advocacy inspired by and managed by people with mental health problems themselves.’ Some 80 per cent of participants have been able to recover or manage their symptoms sufficiently to start earning their living again, Underhill says.
While formal counselling or psychotherapy rarely if ever features in the projects BasicNeeds supports – ‘It’s hard to imagine one-to-one counselling in such resource-poor areas,’ Underhill says – the self-help groups provide a vital peer support function. ‘These groups are not overtly therapeutic; they are designed to help the participants save and provide credit to each other and to represent the views of mentally ill people in a given district, and in other social and civil activities. But these inclusive structures do help to make people feel less alone and more valued and, of course, working on issues that are important to them and their community is crucial to survival.’
1. Bass, JK, Annan J, McIvor Murray S, Kaysen D, Griffiths S, Cetinoglu T, Wachter K, Murray LK, Bolton PA. Controlled trial of psychotherapy for Congolese survivors of sexual violence. New England Journal of Medicine 2013; 368(23): 2182–2191.