ARTICLES

 

Psychosocial humanitarian interventions in the global South: the potential contributions of social work and community psychology

 

 

Ashraf Kagee

Department of Psychology, Stellenbosch University, South Africa. skagee@sun.ac.za

 

 

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ABSTRACT

This article makes the case for the fields of social work and community psychology to contribute to psychosocial humanitarian interventions in the global South. Many countries in the majority world face humanitarian crises, including war, political turbulence and in some cases genocide. In this article I examine some of the interventions that have demonstrated some efficacy in ameliorating psychosocial problems associated with conflict and war; I examine the role of mental health professionals in preparing survivors of war crimes and human rights abuses for testimony in post-conflict truth commissions; and I examine the complementary role of community psychologists and social workers in the context of conflict-related work. In defining a role for social workers and community psychologists, I identify areas of common concern for psychosocial humanitarian aid workers, namely an awareness of power relations, the potential mismatch of cultural zeitgeists between the professions of social work and psychology and the populations they serve, and the cultural sensitivities associated with what is considered to be therapeutically appropriate.

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INTRODUCTION

Many parts of the world have been and continue to be affected by war and political conflict. Wars in countries such as Iraq, Afghanistan, the Democratic Republic of Congo and Palestine have created considerable social and political upheaval over the past several years. The United Nations High Commission on Refugees estimates that 65.6 million people have been forcibly displaced worldwide (UNHCR, 2017), of which 22.5 million are refugees. It is also estimated that there are 10 million stateless people who do not have a nationality or access to education, health care, employment and freedom of movement (UNHCR, 2017).

In the last two decades there has been increased recognition of the need to provide psychosocial humanitarian care to communities that have been affected by war and displacement (Brown, Graaff, Annan & Betancourt, 2017). This means that the role of mental health workers, including social workers and psychologists, has been brought into focus in many areas around the globe. Principles of human rights and social justice form the basis of the social work profession and to a large extent inform the work of many community psychologists. The professions of clinical and counselling psychology and social work have not historically been as active in humanitarian settings in the global South as some other fields such as medicine, disaster relief and humanitarian aid. Yet the potential exists for both fields to apply their working principles, given the considerable need for psychosocial support for refugees, internally displaced persons, and those affected by war and political turbulence.

This article draws on the relevant empirical and conceptual literature and argues for a synergy between the helping professions such as psychology, counselling and social work in addressing the psychosocial needs of communities affected by war and political conflict. First, I present evidence of the need for psychosocial interventions in conflict zones. I then review the interventions to ameliorate the psychosocial problems associated with political conflict and war, and call attention to the role of mental health professionals in preparing survivors for testimony. I provide an overview of the contribution of community psychology and its relevance to social work. Finally, I address areas of common concern for psychosocial humanitarian aid.

Psychosocial problems are ubiquitous among survivors of war and conflict. From a mental health point of view, disorders such as major depression, generalised anxiety, post-traumatic stress, substance use disorders and others are common among adults and children alike. The following are some examples of studies to this effect.

• In Gulu, Northern Uganda, among a sample of 205 adolescents, four years after the end of the 20-year-long civil war, 57% of adolescents had clinically significant levels of PTSD symptoms (McMullen, O'Callaghan, Richards, Eakin & Rafferty, 2012).

• In post-conflict Sri Lanka, among primary health care patients, the prevalence of major depression was 4.5% (95% CI: 4.1-4.9) and mild depression was 13.3% (95% CI: 12.7-13.9) (Senarath, Wickramage & Peiris, 2014).

• Among 720 Nepalese, after the civil war, 27.5 % met the diagnostic threshold for depression, 22.9 % for anxiety, and 9.6 % for PTSD, as measured by the Beck Depression Inventory, the Beck Anxiety Inventory and the Posttraumatic Stress Disorder - Civilian Version (PCLC), respectively (Luitel, Jordans, Sapkota, Tol, Kohrt & Thapa, 2013).

• Among Rwandan survivors of the 1994 genocide, 81% had experienced a traumatic event and 25% met the criteria for post-traumatic stress (Rieder & Elbert, 2013). More than a third of participants endorsed symptoms that indicated clinically relevant anxiety, and more than one fifth had symptoms of depression, on the Hopkins Symptom Checklist.

• Among 98 adult asylum seekers in Australia, the prevalence of major depression and post-traumatic stress was 61% and 52%, respectively, as assessed by the Mini-International Neuropsychiatric Interview (Hocking, Kennedy, Sundram, 2015).

• In a systematic review of 29 studies of a total of over 16,000 war refugees, prevalence rates of depression and anxiety were found to range widely (Bogic, Njoku & Priebe, 2015), although typically estimates were found to be in the range of 20% or higher.

The above are selected examples of the considerable psychosocial burden that typically occurs in societies that have undergone political turbulence. Political conflict in many countries in the global South has shown little sign of abating and therefore it is to be expected that psychosocial problems will continue to be experienced in populations where political turbulence is rife.

 

INTERVENTIONS TO AMELIORATE PSYCHOSOCIAL PROBLEMS ASSOCIATED WITH POLITICAL CONFLICT AND WAR

The Inter-Agency Standing Committee (2010) Reference Group for Mental Health and Psychosocial Support in Emergency Settings has called attention to the need for psychosocial care in the context of war and other emergencies. According to the IASC, psychosocial problems include pre-existing, emergency-induced, and humanitarian aid-induced social problems. Examples of pre-existing social problems are the oppression or marginalisation of specific groups such as Tutsis in Rwanda, Kurds and Yazidis in Iraq, Palestinians in Gaza and the West Bank, and Bosnians in the former Yugoslavia. Examples of emergency-induced social problems are family separation following war, threats to physical safety, disruption of community and social networks, destruction of livelihoods and community structures, human trafficking, the phenomenon of child soldiers, and sexual slavery. Humanitarian aid-induced social problems may include overcrowding and lack of privacy in refugee camps and the disruption of traditional support systems that are brought about by the necessities of humanitarian aid (IASC, 2010).

Various psychological approaches have been applied in conflict and post-conflict settings. These include:

• Psychological first aid, an evidence-informed psychological approach aimed at reducing distress among individuals following a traumatic event (Brymer, Layne, Jacobs, Pynoos, Ruzek, Steinberg, Vernberg & Watson (2006), which has been used in Gaza and Iraq, inter alia.

• Group interpersonal therapy to reduce depression (Bolton, Bass, Neugebauer, Verdeli, Clougherty, Wickramaratne, Speelman, Ndogoni & Weissman, 2003), which has shown efficacy in rural Uganda.

• Narrative exposure therapy with Rwandan genocide orphans (Schaal, Elbert & Neuner, 2009).

• Interpersonal psychotherapy for Sudanese refugees in Egypt (Meffert, Abdo, Alla, Elmakki, Omer, Yousif, Metzler & Marmar, 2014).

• Relationship-based supportive counselling with Liberian and Sierra Leonian torture survivors living in the refugee camps of Guinea (Stepakoff, Hubbard, Katoh, Falk, Mikulu, Nkhoma & Omagwa, 2006).

• Culturally responsive play therapy with Somali refugees (Killian, Cardona & Hudspeth, 2017);

• Community gardening as a way of providing social support with Nepali Bhutanese refugees (Gerber, Callahan, Moyer, Connally, Holtz & Janis, 2017).

In the context of such interventions, overarching principles have been developed to guide efforts to ameliorate psychosocial distress. In an account of the development of humanitarian psychology, Jacobs (2007) offers seven principles for designing appropriate psychosocial support programmes aimed at humanitarian relief. These are that (1) programmes should do no harm; (2) programmes should be community-based; (3) programmes should be sustainable; (4) programmes should build on the strengths of the community being served; (5) programmes should use local expertise; (6) programmes need to primarily address ordinary reactions to extraordinary events; and (7) every person in the area affected by political conflict should be offered psychological support. Jacobs (2007) acknowledges that this last principle is not uniformly endorsed by professionals in the field. In the context of evidence of the iatrogenic effects of some interventions to reduce symptoms of traumatisation (Rose, Bisson, Churchill & Wessely, 2002), the principle of offering every person psychological support should be considered in the context of the principle of doing no harm. For example, critical incident stress debriefing is a psychosocial intervention typically offered to all individuals who have experienced a traumatic event, regardless of whether they are symptomatic (Carlier, 2000). As such, it is considered a prophylactic intervention to offset the development of symptoms of traumatisation. Yet, evidence suggests that debriefing may actually inhibit the spontaneous remission of such symptoms (Rose, et al., 2002). The recommendation that everyone in a conflict area should be offered critical incident stress debriefing therefore needs to be tempered with careful analysis of the evidence that such an approach is indeed beneficial for the majority of recipients. The data as indicated by the Rose et al., 2002 Cochrane Review suggest that this may not be the case.

Psychosocial interventions in such war-affected areas also need to follow a tiered approach. At a very basic level, tasks that require urgent attention include reuniting children with parents, ensuring the physical safety of refugees and internally displaced persons, and addressing basic food and shelter needs. It would appear that social workers and community health workers are uniquely positioned to facilitate such processes.

At a second level, there is the need to intervene to stop human trafficking, including that of girls and women for sex work, and creating ways to rescue children from forced combat. Law enforcement officials, policy makers, immigration officials, peace-keeping military personnel and legal experts have a considerable role to play in this regard, and in this sense complement the work of mental health professionals.

At a third level in post-conflict situations, there is the need to restore community and social networks and traditions. To a large extent mental health professionals, including social workers and psychologists, may assist in facilitating such processes. Interventions may take the form of individual, family and group counselling aimed at ameliorating psychological disturbance such as symptoms of traumatisation, depression, anxiety, marital and family discord, and substance abuse problems that occur as a consequence of surviving war trauma. Interventions may also take the form of facilitating community and social processes aimed at engendering restorative justice. As explained below, South Africa's Truth and Reconciliation Commission provides examples of how psychologists can make a contribution in this regard. Thus, community psychologists and social workers have a role to play in providing services to survivors of humanitarian disasters, each with their own disciplinary assumptions and professional practices.

 

THE ROLE OF MENTAL HEALTH PROFESSIONALS IN PREPARING SURVIVORS FOR TESTIMONY

Social workers and psychologists may also serve those affected by war and conflict by preparing survivors of human rights violations for testimony with a view to engaging in processes aimed at restorative justice. In some post-conflict areas such as Brazil, Argentina, Chad, the Democratic Republic of Congo, Chile, Guatemala, Liberia, Nigeria, Sierra Leone and South Africa, truth commissions have been instituted to create a process of social reconciliation between former enemies. Typically, such commissions are official legal mechanisms that aim to discover and bring to public attention past human rights violations such as executions, disappearances, torture, massacres, and genocide. Such processes have been instituted following internal conflict, civil war or military dictatorship.

One of the crucial aspects of a truth commission is the act of testimony of survivors of political repression. In as much as testimony is part of the legal and political process of a truth commission, it is also undoubtedly a personal, psychological and communal process that may bring to the fore unprocessed trauma, grief and loss. Psychosocial support in such instances fulfils psychological, social and political functions. Support assists those giving testimony to retain psychological functioning, which is in and of itself a personal and social good. Persons providing testimony who are well-functioning can therefore do so effectively and thus contribute to the truth-finding process and to national reconciliation. Hence, professionals who provide psychosocial support in the form of counselling and psychotherapy - such as social workers, psychologists, counsellors and therapists -have a prominent role to play in assisting persons providing testimony and their families in emotional and psychological processing.

Yet truth commissions are often insufficient in fostering long-term opportunities for peace. Political reconciliation is a process that may take years or even decades to achieve. Thus the contributions of peace psychology and social work seek to achieve these long-term objectives by means of policy-making, peace education and social mobilisation. Community development processes aimed at fostering long-term peace may take the form of non-violent conflict resolution and management, conflict mediation, peace and reconciliation workshops, and providing expert advice in the development of social policy aimed at enhancing peace. The professions of social work and psychology are uniquely positioned to contribute to these processes by means of initiating, supporting, and sustaining them. In some instances, such as in the provision of counselling and psychotherapy, the roles of psychologists and social workers may be interchangeable. In areas such as psychometric testing, developing and testing novel psychological treatments, and conducting monitoring and evaluation exercises with an emphasis on psychological measurement, psychologists may be more appropriate. In areas such as non-governmental organisational development, reuniting family members with each other, facilitating community processes such as peace-building exercises, social workers may be more appropriate, although these tasks are not mutually exclusive.

 

THE CONTRIBUTION OF COMMUNITY PSYCHOLOGY AND ITS RELEVANCE TO SOCIAL WORK

Unlike social work, which intervenes at the level of the individual, family or community, the fields of clinical and counselling psychology have traditionally regarded the individual as the unit of analysis and intervention. Even when clinical interventions are rendered in a group context, such as family or group psychotherapy, the assumption in psychology is that individuals, rather than communities or society as a whole, undergo psychological change. Thus, psychological interventions are focused on the individual whose personal, social, material and instrumental resources are harnessed to effect therapeutic change. In the last few decades community psychology has offered an alternative approach to individual-focused psychology. The field has advanced to the extent that several psychology and social work training programmes have incorporated the principles of community psychology in their curricula.

Community psychology has been defined as being concerned with the relationships of the individual to communities and society (Dalton, Elias & Wandersman, 2001). To this end, the field is imbued with a set of ontological and epistemological assumptions that inform its practice. According to Orford (2008), the central idea of community psychology is that people's functioning is best understood in the context of their social environments. Both social work and community psychology thus seek to conceptualise psychological change as occurring beyond the individual. It focuses on the concept of the community, in whichever way it may be defined, as the unit of analysis and intervention. A community psychology approach therefore brings into focus the emerging properties of individuals, groups and processes in terms of epistemic primacy. Families, peer groups, organisations and institutions, geographical catchment areas, and identity-based communities such as LBGTI, disabled or ethnic-based communities may form the basis of conceptualisation, analysis and intervention in both the community psychology and the social work approach. Furthermore, rather than conceptualising psychological processes in terms of linear causality, community psychology has historically embraced a systemic approach to understanding psychological and community processes (Bronfenbrenner, 1979). Hence, individuals are seen as active players who exercise volition and agency in their social settings whilst also remaining influenced by their context. Psychological processes, both intra- and extra-individual, are thus dynamic, non-linear, emergent and reciprocal.

In many texts on community psychology, paradigmatic and theoretical issues are brought into focus with the field's emphasis on the social context in which individuals and communities find themselves. For example, Bronfenbrenner's (1979) ecological model places an emphasis on the macro-, meso- and microsystems that influence and are influenced by one another. This model has been extensively used in both community psychology and social work case conceptualisation. In the context of humanitarian psychosocial care, a community psychology approach brings into focus the tension between an ameliorative and a transformative agenda for social and individual change (Bhana, Petersen, Rochat, 2007).

On one hand, it may be argued that psychosocial services assist individuals and communities in adapting to their contexts of social and political conflict by seeking to ameliorate psychological distress and dysfunction. Such a view frames psychological adaptation as inhibiting the agency of individuals and communities to transform their social and political environments. On the other hand, the consequences of war trauma are undeniably severe and may precipitate high rates of mental disorders, which may severely affect the ability of people to engage in daily functioning, including caring for children. Yet it is undeniable that psychosocial services are imperative and necessary under conditions of extreme conflict and war, and that attending to psychosocial needs is a humanitarian priority.

In many conflict-affected areas NGOs that provide psychosocial services operate at the margins of power and influence. For example, a Ugandan NGO providing counselling services to male refugee survivors of war rape from the Democratic Republic of Congo has been placed under surveillance and has faced the threat of closure by the Ugandan government (Anonymous, 2015). The pretext used is that by providing psychosocial care to male rape survivors, the organisation supposedly promotes homosexuality, which is illegal in Uganda. If it were to actively pursue a transformative agenda by promoting human rights, including rights related to sexual diversity, the organisation would be forced to close and its staff would be arrested. Thus, by virtue of the physical and legal dangers posed by an oppressive political regime, its agenda is necessarily ameliorative in that it seeks to reduce psychological distress and enhance coping and resilience among its service users. Such an ameliorative approach that seeks to promote adaptation and therapeutic change is therefore both politically pragmatic and presumably practically achievable.

The argument here is not that community psychology and social work are interchangeable. Instead, attention is called to the positive contributions of both fields, which as helping professions share several epistemological and ontological premises. Both call for a transformative agenda even though there may be competing priorities and agendas on the part of the major political and military players in the aftermath of political conflict. This means that psychosocial support is unlikely to be high on the list of priorities. Yet social work with its emphasis on advocacy work is likely to make a significant contribution by placing post-conflict transformation on the agenda of policy makers and government officials and by contributing to social policy.

 

AREAS OF COMMON CONCERN FOR PSYCHOSOCIAL HUMANITARIAN AID

There are three area areas of common concern for the psychosocial humanitarian aid community. These are the power differential between service provider and service user; the potential mismatch between the political and social zeitgeists of donor and recipient societies; and the need to ensure cultural sensitivity of interventions rendered.

Power relations: The role of power relations forms the basis for analysis with a community psychology approach. Individuals who experience psychological difficulties as a consequence of traumatic experiences associated with war are in many contexts marginalised, oppressed and vulnerable. Mental health professionals, including psychologists and social workers, are well-suited to providing psychosocial interventions aimed at enhancing resilience and coping. In politically stable societies the difference in power between service provider and service user inevitably finds expression in the dynamics of psychotherapy, despite theoretical commitments and practical efforts to narrowing such differences. In societies affected by war and conflict, it is likely that such power differentials may be magnified, as service users may be displaced and stateless, and may have endured multiple losses, including the loss of family members and property. Service providers, on the other hand, are likely to be employed, salaried and in possession of professional skills as well as social and intellectual capital. Thus the power differential between service provider and service user is a matter to be considered by the professions of social work and psychology working in the area of psychosocial humanitarian aid.

Potential mismatch of Zeitgeists: In liberal democracies the assumptions of individual liberty and social equality are axiomatic. Thus various freedoms, including freedom of expression, religious practice and movement, are considered inalienable rights. In addition, in many countries victories on the fronts of gender equality, sexual diversity and disability rights have been won over the past several decades, to the extent that discrimination on these dimensions of identity is considered unacceptable and often illegal. Yet in many countries that have experienced war and conflict, basic human rights are routinely violated and in fact form the basis of conflict. Oppression and human rights violations on the basis of gender, race, ethnicity and religious practice inform the social fabric in fundamental ways. Examples include the Taliban in Afghanistan discouraging or prohibiting women's education, imprisoning or issuing death threats against so-called creators of "blasphemous" art works, such as in Iran or Pakistan, or outlawing homosexuality as in Uganda and other countries. Individual freedoms, including freedom of expression, form part of the cultures of helping professions such as psychology, counselling and social work. It is possible that there is a mismatch between these professions, on one hand, and elements in societies where humanitarian aid is dispensed, on the other, which may create tensions for the provision of psychosocial services. This is an area for some reflection in the fields of social work and psychology.

Cultural sensitivities: Another element of potential mismatch is the assumption that psychological interventions should always involve talking therapies, where service users are required to discuss their problems verbally. In some societies verbal expression is not assumed to be psychologically or therapeutically healing and in fact may inhibit other forms of self-expression such as silence, art work and rituals. Religious rituals have also often been omitted from practices that form part of the skill repertoire of the helping professions, with the exception of pastoral counselling. In fact, it has been argued that NGOs do not adequately attend to the spiritual and religious needs of the people they serve even though spirituality may assist in coping with the catastrophic events (Onyango, Paratharayil, van den Berg, Reiffers, Snider & Erikson, 2011). In many societies religious practices form an essential part of human interaction and meaning-making, including dealing with death, grief and bereavement. Omitting religious rituals from therapeutic engagement may limit the uptake, acceptability and efficacy of psychosocial services provided in the context of humanitarian aid.

These examples, i.e. power relations, the potential mismatch of zeitgeists and cultural sensitivities, represent areas of concern for the fields of social work and psychology when working in post-conflict areas. It is necessary therefore for members of both professions to maintain a critical awareness of the need to constantly engage with these concerns with a view to engaging in critical practice.

 

CONCLUDING REMARKS

Given emerging evidence of efficacy of psychosocial interventions in the context of political conflict and war, both psychologists and social workers have the potential to reduce psychological dysphoria among affected persons to the extent that improved psychological functioning is possible under adverse conditions. In this article I have argued for the considerable need for psychosocial services in war-affected areas, and the particular contribution that social workers and psychologists can make in this regard. There are specific interventions that are informed by an evidence base and may be applied by such professionals to ameliorate psychosocial problems associated with political conflict. In post-conflict situations mental health professionals have a particular role to play in preparing survivors for testimony, for example, in the context of truth commissions or courts of law where perpetrators are held to account for war crimes. Finally, I have called attention to areas of common concern for psychosocial humanitarian aid workers when operating in geographical and social contexts that are at variance with their professional cultures. The nature of this work is not without its pitfalls, given the potential mismatch in power relations and differing assumptions about how psychological change may come about. Indeed, future research is needed to understand the role of cultural rituals, indigenous healing practices and local knowledge in bringing about therapeutic change among persons affected by war trauma.

 

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