Over the last two decades, attention has increasingly been paid to the psychosocial well-being of people affected by war. Humanitarian agencies have argued that the effects of violent conflict result not only in material and physical suffering, but also in emotional, spiritual and psychological distress. The interest in providing psychosocial assistance has led to a rapidly expanding trauma industry. A large variety of programmes are instituted in war-affected areas, all of which claim to be alleviating psychosocial distress or trauma in one form or the other. According to a European Community Task Force review, in the former Yugoslavia in 1995 there were 185 such projects, being implemented by 117 organisations. This proliferation of psychosocial programmes has gone hand in hand with the popularisation of the notion in the West of trauma and Post-traumatic Stress Disorder (PTSD). PTSD was first identified in US Vietnam veterans, who experienced social-adjustment problems and psychological symptoms, such as flash-backs, withdrawal and restlessness. It has since come to dominate the way in which researchers and agency workers talk about the effects of war.
This conceptualisation of distress and the emphasis placed on the traumatisation of entire populations has been criticised in recent years. It has been argued that the trauma model is inappropriate in non-Western cultures, and that psychosocial programmes do not reflect the expressed needs of war-affected people themselves. Critics maintain that psychosocial programmes largely ignore the role that culture plays in issues of distress and mental health, and that treatment and intervention practices tend to use uniform approaches, implemented regardless of the differing social, political and cultural context. In Mozambique and Angola, for example, people use traditional healers and diviners to help them with problems caused by the vengeful spirits of those unjustly killed. In such a context, some critics argue, it is inappropriate to use Western psychological methods based on ideas about talking through ones emotions and memories.
Among aid workers, there is confusion as to what type of psychosocial programme may be appropriate in particular situations, and whether emphasis should be placed on therapeutic or community-focused interventions. Some agencies set up counselling centres, and train staff members in counselling techniques and other forms of therapeutic activities, where drama, drawing and play are used to help survivors confront and cope with their experiences of war and displacement. Other agencies argue that it is most important to help communities rebuild the structures that are central to their social networks, such as places of worship, communal meeting areas and schools. Psychosocial well-being, these organisations argue, is enhanced and facilitated through the social support members of a community offer one another.
The Refugee Experience
In the light of these complex issues, the Refugee Studies Centre at the University of Oxford and the Centre for International Health Studies at Queen Margaret University College in Edinburgh have produced a training module for humanitarian workers, entitled The Refugee Experience. Editors Maryanne Loughry and Alastair Ager invited a number of authors in the field of forced migration to reflect on a psychosocial understanding of the refugee experience. The resulting module, first issued in 1999 and revised last year, is designed for humanitarian workers and refugee policy-makers who do not necessarily have a professional background in the social sciences, but who wish to gain insight into the psychosocial dimensions of working with conflict-affected refugees.
The two-volume module provides an overview of the current debates and issues in the field of psychosocial assistance to war-affected populations, as well as training materials, such as notes for facilitators, additional references, ideas for an interactive cross-cultural game and a glossary of relevant terms. It introduces the dominant psychological explanations for the experiences and behaviour of refugees and forced migrants and, as a way of explaining many of the issues confronting refugees, presents a case example of a Rwandan refugee seeking asylum in Canada. The example is statistically untypical of the majority of refugees, who seek asylum in neighbouring countries rather than in countries of the industrialised world. It does, however, demonstrate some of the common challenges and problems of adjustment, adaptation, fear, identity and belonging that form part of the refugee experience.
The main volume consists of a series of discussion guides that focus on various aspects of psychosocial work. Derek Summerfield analyses the nature of modern warfare and its implications for psychosocial responses. Mary Diaz, the Executive Director of the Womens Commission for Refugee Women and Children, investigates issues pertaining to gender and displacement, discussing topics such as the situation of girls affected by armed conflict, mental health, reproductive health concerns, income generation and the empowerment of displaced women. The psychosocial needs of refugee children and adolescents are examined by Margaret McCallin, who stresses the need to contextualise discussions within a child-rights framework. McCallin also addresses critical issues such as separation, education, exploitation and under-age soldiers.
Non-Western concepts of mental health are discussed by Alcinda Honwana, who looks at how mental health and illness are understood in cultures that do not primarily use biomedical explanations for making sense of these illnesses. She examines how mental health is understood by local people; how it relates to war and other social crises; and how people deal with the social and emotional problems caused by armed conflict. Inger Aggers chapter focuses on how aid workers can help protect the sense of sanity and dignity of the people they assist. Agger presents a case example of a psychosocial project in Croatia, outlining the reasoning behind decisions made to constitute a therapeutic group. She discusses the approaches currently used, based on rights, trauma, culture and gender, and argues that there are no universal right or wrong methods for providing psychosocial assistance.
The module also raises concerns about the evaluation of psychosocial programmes. It has frequently been pointed out that evaluation in this area is scarce or non-existent, as many agencies rely mainly on anecdotal evidence to substantiate their claims of successful interventions. Alastair Ager identifies two main questions that programmes need to pose: what are we appropriately seeking to achieve?; and what is the best way of going about this?
He suggests that evaluation should be built into the programme planning and implementation phases of a project, rather than added as an after-thought, or avoided altogether.
The second volume also includes a section on developing communication and helping skills with participants. The development of these skills assists humanitarians to work effectively in conflict and post-conflict situations by improving the quality of their working relationships. Emphasis is placed on a community-participation approach; Eva Segerstroem, who has worked with organisations such as Rädda Barnen (Swedish Save The Children), describes some of the skills and processes involved in applying the principles of community participation in practice. Community participation is primarily seen as aimed at meeting the right to self-determination, and as a basis for strengthening the communitys own resources, thus enabling refugees to develop structures for identifying and responding to the needs of individuals, families and the wider community.
Carola Eyberwas a Research Assistant at the Refugee Studies Centre, Oxford University.
The Refugee Experience can be accessed at www.forcedmigration/rfgexp. For further information, please contact Maryanne Loughry (firstname.lastname@example.org) at the Refugee Studies Centre, University of Oxford.
References and further reading
A. Ager, Tensions in the Psychosocial Discourse: Implications for the Planning of Interventions with War-affected Populations, Development in Practice, vol. 7, no. 4, 1997, pp. 402407.
J. Boyden and S. Gibbs, Children of War: Responses to Psycho-social Distress in Cambodia (Geneva: UNRISD, 1997).
P. Bracken and C. Petty (eds), Rethinking the Trauma of War (London: Free Association Books, 1998).
L. McDonald, The International Operational Response to the Psychosocial Wounds of War: Understanding and Improving Psycho-social Interventions, Working Paper 7 (Medford, MA: Feinstein International Famine Center, 2002).
D. Summerfield, Sociocultural Dimensions of War, Conflict and Displacement, in A. Ager (ed.), Refugees: Perspectives on the Experience of Forced Migration (London: Pinter, 1999).