BEYOND TRAUMA: ADDRESSING PSYCHOSOCIAL SUFFERING

By Ananda Galappatti
Psychosocial Advisor/Coordinator
The Mangrove: Psychosocial Support and Coordination Network, Sri Lanka

Presented at the 2008 Magsaysay Awardees' Lecture Series,
Magsaysay Center, Manila, 2 September 2008

The field I work in is commonly represented as being about the provision of psychological support to people in terrible emotional distress after experiencing a traumatic event. The images in the popular imagination and in the media often are of counsellors or psychiatrists compassionately listening to or treating victims of violence, or survivors of disaster. Whilst these forms of help are still very important to the field of mental health and psychosocial support in the context of conflict and disaster, they are now by no means the only way in which it seeks to assist people affected. I would like to share with you some of the key changes that have taken place in this field over the past decade - and also discuss what is being done to address psychosocial suffering in a developing country affected by chronic conflict and major disaster. In some ways, this story also traces the shifts and trajectories of my own work in Sri Lanka since I entered the field in 1996. At that time, because of the continuing war between the government of Sri Lanka and separatist militants in the North and East of the country, and also a recent failed but bloody insurrection in south, western and central Sri Lanka, numerous services had arisen to deal with the psychological consequences of this violence - mostly provided by non-governmental organisations and to a lesser extent by the state. Due to the globalized nature of the field (that is, in terms of knowledge, technical expertise and financial resources typically flowing from North America and Western Europe to poorer conflict-affected countries), the approaches in Sri Lanka closely mirrored those in other similar contexts. Whilst this trend continues today, the development of local expertise and consolidation of experience within the island is beginning to change this dynamic.

The Clinical Model

If we return to the popular stereotype of my field of work; this representation has its roots in the origins of work in this area. When the field of mental health work with refugees first emerged in the 1980s, as a part of the new professionalised humanitarian interventions with refugee populations affected by war and disaster in the developing world, the perspective that dominated this work was that of psychiatry and clinical psychology. It was recognised that civilians affected by the terrible events of war or disaster often had consequences that went beyond material loss or physical injury. Psychological problems like depression, overwhelming grief reactions, anxiety and post-traumatic stress were identified as key issues to address. As a result, the psychotherapeutic and medical approaches that had been developed in Europe and North America to address these same issues in civilian and war-veteran populations were deployed through clinics or community mental health programs in conflict-affected countries. In Sri Lanka, this meant the establishment of programs to train counsellors and medical staff to identify people with the symptoms of particular mental disorders and provide them with talk-therapies or drug treatment. Their services were provided through hospitals, centres in the community and home-visits. For children, there was an added concern that their stressful experiences might impair their psychosocial development and pre-dispose them to later mental health problems, or that exposure to violence could lead to antisocial or violent behaviour in the future. In Sri Lanka, this again led to the development of programs for children to work through their experiences using art or play, as well as to many training initiatives for teachers to better help their conflict-affected pupils.

When I began work in this field in 1996, as a volunteer with an organisation supporting survivors of torture in Sri Lanka, this was very much the paradigm within which we worked. Our clients were provided with sessions with counsellors to help them talk through the various emotional, existential, relational and practical problems that they encountered. Although the model of care was relatively progressive in that it recognised that our clients and their families had many difficulties beyond the purely psychological, and attempted to provide a 'holistic' care package, these services were all compartmentalised. Medical care and physiotherapy for physical injuries, provision of assistance in job-seeking or grants for income-generation, legal assistance in seeking justice and counselling for psychological difficulties were each delivered separately and with little reference to each other. What we could not see at the time was that many of the different problems of torture survivors were actually inter-related, and that our attempts to assist them could have been more meaningfully integrated.

Although clinical and psychologically-oriented interventions still dominated the field in the mid 1990s, these had also begun to draw criticism internationally. One argument was that they focussed too narrowly on individual psychological states and ignored the broader social circumstances and problems that produced and shaped distress. It was also claimed that the 'medicalized' approach emphasised the role of external experts, failed to recognise or make use of the local resources available to affected persons and communities, and undermined survivors' roles in effecting their own recovery. The focus on 'vertical' specialist services targeting small well-defined groups (i.e. torture survivors, people with PTSD, survivors of sexual violence, etc) was also argued to be at the cost of more 'horizontal' general support that could be provided to entire populations, and which would avoid the stigmatisation or differentiation of particular individuals. Lastly, there was a suggestion that the Euro-American concepts such as post-traumatic stress disorder were not appropriate to use in capturing or addressing the suffering of people in non-western settings.

The debate this criticism provoked between what has been described as the 'trauma' and 'resilience' camps was quite vigorous and at times even bitter. These exchanges mostly took place in European and North-American academic and humanitarian policy arenas, although their effects were felt in terms of the design and financing of programmes in conflict-affected countries. In Sri Lanka, whilst we were vaguely aware of the specific disagreements taking place, our own concerns about the clinical model were first shaped by the practical experiences of implementing it. Clients were not always comfortable with or convinced of the value of talking-treatments, preferring practical interventions around the concerns associated with their psychological distress. Often there was divergence in the way that clients and service providers conceptualised or prioritised problems. Limitations in resources for training and supervision meant that the quality of 'barefoot' counselling or 'psychiatry-lite' being offered was often low. The fact that most clients continued to live in communities where violence and conflict continued also presented challenges to therapeutic progress.

Understanding Social Suffering and Integrating MHPSS

By the end of the 1990s, I had joined a few colleagues in trying to articulate alternative visions of what support to individuals and communities might look like. We drew inspiration and insight from our unsatisfactory experiences with the institutional and theoretical elements of the clinical model, from snippets we read of the Euro-American debates within the field or the emerging work of medical anthropologists on social suffering, and most significantly from research and reflection on the nature of women's suffering Sri Lanka's conflict zones.

Whilst conducting research and being involved with service delivery, my colleague Gameela Samarasinghe and I were confronted with the realities of women's lives under conditions of ongoing war in Northern Sri Lanka and also in the disadvantaged South-Eastern part of the island where an armed insurrection had been suppressed some years earlier. The impacts that they described caused us to look beyond purely psychological disorders and effects, and adopt a more 'psychosocial' perspective that aimed to acknowledge how events and circumstances shaped both their inner psychological and external social worlds, and how these two domains continued to interact with each other. For instance, the murder of her husband might not only cause a woman grief, a sense of powerlessness and existential doubts, but also new challenges in terms of material and economic survival, increased vulnerability to sexual violence or exploitation, and changes in social identity and relationships with her children, relatives and neighbours. It was clear also that these impacts had knock-on effects many years down the line, and that the suffering of conflict lay on a continuum with other forms of violence and hardship that women experienced even when the fighting was over. The powerful way that poverty undermined women's abilities to cope with losses or threats was also evident. The lack of disposable assets like jewellery or savings to mobilise in a crisis, not owning land or livestock from which to make a living, the lack of salaried income, and the absence of skills or connections to be able to find work and negotiate the public domain were all often associated with greater difficulty and distress. The insights gained from these women's lives were crucial in our understanding the contours of the suffering of adults and children in disadvantaged and chronically affected communities.

If the psychosocial consequences of conflict were mediated and shaped by the social and structural conditions of people's lives, we felt that our interventions to support survivors had to engage with these, and not simply the individuals affected. In a 1999 manifesto-of-sorts, we declared our intention to integrate approaches conducive to enhancing psychosocial wellbeing into mainstream development and humanitarian work, and since then have worked to put this into practice. Happily, the team of colleagues with whom I began this work was not the only group to converge on this objective in Sri Lanka at around the same time, and we have enjoyed some rich collaboration and exchange of parallel ideas and approaches as a result. In recent years, we have begun to dialogue with and lobby policy-makers and mainstream development practitioners, whilst we also strive to better understand the linkages between long-term and large-scale development processes and the wellbeing of individuals and groups affected by these. Our work also fits into a broader trend within the field at large, and just last year, the Inter-Agency Standing Committee (that is the executive committee of the UN and a number of large consortia of international NGOs) issued authoritative guidelines on mental health and psychosocial support interventions in situations of emergency that emphatically argues for the need to support individuals and populations through activities directly related to provision of shelter, education, food and information - but which impact strongly on psychosocial wellbeing and mental health.

This incarnation of mental health and psychosocial support work looks remarkably different from the popular image that I invoked at the beginning of my talk. Whilst we still retain and value the individual therapeutic workers doing one-to-one or group work with affected people, increasingly the emphasis is on less obvious processes. These might typically involve any of the following: the way in which people being resettled are well informed about the place to which they will go, their ability to choose their neighbours (relatives or people they knew before as opposed to strangers) or influence the layout of their house; ensuring that orphans can find foster homes within their own communities (rather than be institutionalised), helping teachers prevent discrimination against orphan children in school or reuniting siblings who have been separated after the loss of their parents; helping widowed women become more skilled in running home-businesses, ensuring a match between their products and market demand, and creating opportunities for new friendships and partnerships between them and other women in the community; establishing clear complaint and advocacy mechanisms in refugee camps, ensuring that camp administrators don't privilege particular individuals and groups, or coordinating the way different agencies interact with and provide assistance to a single camp.

What It Takes

The new approaches that we are working with now have their own challenges. The greatest of this is that these new strategies require new skills on the part of those who wish to intervene - encompassing and going beyond the clinical techniques offered by the professions of psychiatry and psychology. We have needed to draw in persons with skills in the areas of poverty-alleviation and micro-credit, community-building and social mobilisation, local social and healing practices, camp-management, protection and legal aid, education, healthcare and shelter, providing them with new understandings of how their actions in these fields can contribute to enhancing psychosocial wellbeing and mental health. People who wish to specialise in this increasingly multi-disciplinary area of work require innovative and broad training. In Sri Lanka, like a handful of locations around the world, we have started running courses on mental health and psychosocial support for professionals and community workers, both in our universities and in affected areas. We try to ensure that learning that emerges from our new initiatives and developments in the field, especially in our own contexts, are quickly reflected in the curricula of the training we offer.

Working in relatively unmapped territory also requires that we continue to re-think and critique our assumptions about the field, even as we try to consolidate and formalise our learning into concrete guidelines on good practice. At the moment, there is renewed interest in Sri Lanka to better understand local socio-cultural frameworks of psychosocial wellbeing, as well as to find better ways of measuring the impact that our interventions have on the dimensions that affected communities consider to be priorities. We are challenged to improve the quality of our dialogue with the individuals and groups whom we are trying to assist, and to give them greater opportunities to participate in the decisions that shape interventions.

We have also been trying to build inter-disciplinary alliances and better partnerships with others sectors of humanitarian response. These linkages and collaborations need to take place at the level of front-line service provision, but also at that of regional or national programmes and policy. At an individual case level, a psychosocial worker may work together with a primary health midwife to support a displaced woman suffering from post-partum depression; at the level of local programmes, psychosocial practitioners and school administrators may collaborate in getting school drop-outs to re-enter education; local government and humanitarian managers may be encouraged at a regional level to adopt standard policies and processes for consulting with affected populations; interventions at the level of central government may include working with the Ministry of Education to develop national curricula and training for teachers on supportive classroom practices for disaster-affected students, or helping to frame policy that diverts children from incarceration within the justice system.

Our experience after the tsunami disaster of 26th December 2004 has taught us many valuable lessons about coordinating services within and across sectors in an emergency context. Granted what we learned in the context of the tremendous and unruly post-tsunami response was as much from our mistakes and narrow misses as from our more successful efforts. Still, valuable skills and experience in cooperative action has been developed within the field, which can be harnessed for future work.

Even as we try to enhance the technical capacity of policy-makers and develop the institutions and structures to deliver psychosocial and mental health support, we have to be doubly aware of the human element that is integral to this area of work. Most of what we do is not very complicated, but our success often hinges on the ability to maintain sensitive and genuine relationships between the persons providing support and those who receive it. The experienced practitioners who were important mentors for me as a novice, as well as the key colleagues to whom I look for guidance, all demonstrate a remarkable capacity to identify the priorities in the lives of their clients, and become a part of the work of addressing these. It often seems impossible for any of them to treat this work as something simply routine, or to fail to connect with the essential humanity of the people they encounter. Yet, whilst this work requires that practitioners engage closely with survivors and their suffering, this often takes an emotional toll that can easily result in workers feeling ineffective, jaded or disinterested - which can spell disaster for our clients. Maintaining healthy, ethical and committed relationships with the people we aim to assist can be greatly aided by the building of small teams and networks of practitioners who reinforce positive professional values practices, as well as provide personal support. In my work, this has probably been the most important ingredient of all.

Shifts in the Global Field

That the Trustees of the Ramon Magsaysay Award Foundation have chosen this particular moment to recognise an Asian practitioner in the relatively young field of post-emergency psychosocial support is, for me, particularly symbolic of how practice in conflict and disaster-affected countries of global South has come of age. When I first entered the field in Sri Lanka, the flows of knowledge and expertise were almost exclusively uni-directional from outside the island. At its best, this meant that services in Sri Lanka benefited from wise and influential international advisors sensitively transferring insights and successes from other parts of Asia, Africa, Europe or North America. At its worst, it meant that initiatives were introduced in Sri Lanka with little attention to how they would interact with local structures, social practices or knowledge systems. However, the long-standing and sometimes pioneering work in Sri Lanka has now meant that a level of experience and expertise has been built up in relation to post-emergency mental health and psychosocial work. This is bringing an increased sophistication and coherence to the work being done in the country, which is increasingly being designed by local practitioners in situ. This is also true for other similar contexts of disaster and chronic conflict, with the result that practitioners from these arenas are beginning to make their mark on the field globally. It is now not uncommon to have practitioners from Jaffna working in Cambodia, or from Gujarat guiding interventions in Aceh. That there is increasing direct exchange between practitioners from similar contexts is very exciting, considering that this has been sorely lacking in the past. Knowledge outlets like Intervention: the international journal of mental health, psychosocial work and counselling in areas of armed conflict, which actively seeks contributions from practitioners working in situations of adversity, as well as emerging initiatives for improving networking amongst psychosocial and mental health workers globally also bode extremely well for developing a dynamic and beneficial dialogue between practitioners and thinkers in affected countries and beyond. I'm looking forward to the coming years of work, collaboration and exchange with great hope that it will move us forward in our ability to provide excellent and effective services to the huge numbers of men, women and children affected by violence and disaster across the globe.