Trauma, Mental Health & Psycho-social Well-being: Key Debates &Implementation Challenges

A series of tensions underlie current debates regarding the conception and implementation of psychosocial interventions with war-affected populations. Professor Alastair Ager synthesizes these tensions as followed: "generalizability vs. uniqueness of relevant knowledge, valuing technical vs. indigenous understandings, planning of targeted vs. community-based interventions. Programs that emphasize more general, technical, and targeted approaches to providing psychosocial interventions may adopt a clinical, decontextualized approach that focuses on individuals. In contrast, those programs that advocate unique, indigenous, and community-based approaches may suggest that there is no role for Western psychosocial work at all in helping alleviate the distress and suffering of populations."1 This section details the elements of debates on three inter-related tensions:

  • The articulation between individual (targeted) and community-wide approaches in the diagnosis, understanding and treatment of trauma issues;
  • The relative value of technical/medicalized approach of trauma (and the merits of the use of PTSD framework in that context) versus psyschosocial understandings that value indigenous understandings;
  • The cultural assumptions embedded in the imported psychological frameworks and the extent to which local cultural frameworks and resources can be used.
A fourth point is added to that list of concerns; it relates to the difficulty of evaluating mental health programs.

Individual vs. community perspectives

Many assert that psychological and emotional healing needs to be addressed at the national, community and individual levels.2 Still, there is much debate around focusing the interventions on communities or on individuals, as well as on whether the needs for recovery for individuals and communities are the same.

Three distinct elements seem to need to be distinguished here: first, the diagnosis (how to understand and describe the nature of the trauma); second, the understanding of the connection between the impact of traumatic experiences for individuals and their collective consequences; third, the way both dimensions should be addressed in the aftermath of conflicts, and how targeted the interventions should be.
Diagnostic criteria for 309.81 Posttraumatic Stress Disorder

A. The person has been exposed to a traumatic event in which both of the following have been present:
(1) the person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others
(2) the person's response involved intense fear, helplessness, or horror. Note: In children, this may be expressed instead by disorganized or agitated behavior.

B. The traumatic event is persistently reexperienced in one (or more) of the following ways:
(1) recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptions. Note: In young children, repetitive play may occur in which themes or aspects of the trauma are expressed.
(2) recurrent distressing dreams of the event. Note: In children, there may be frightening dreams without recognizable content.
(3) acting or feeling as if the traumatic event were recurring (includes a sense of reliving the experience, illusions, hallucinations, and dissociative flashback episodes, including those that occur upon awakening or when intoxicated). Note: In young children, trauma-specific reenactment may occur.
(4) intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event.
(5) physiological reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event.

C. Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma), as indicated by three (or more) of the following:
(1) efforts to avoid thoughts, feelings, or conversations associated with the trauma
(2) efforts to avoid activities, places, or people that arouse recollections of the trauma
(3) inability to recall an important aspect of the trauma
(4) markedly diminished interest or participation in significant activities
(5) feeling of detachment or estrangement from others
(6) restricted range of affect (e.g., unable to have loving feelings)
(7) sense of a foreshortened future (e.g., does not expect to have a career, marriage, children, or a normal life span)

D. Persistent symptoms of increased arousal (not present before the trauma), as indicated by two (or more) of the following:
(1) difficulty falling or staying asleep
(2) irritability or outbursts of anger
(3) difficulty concentrating
(4) hypervigilance
(5) exaggerated startle response

E. Duration of the disturbance (symptoms in Criteria B, C, and D) is more than one month.

F. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
Specify if:
Acute: if duration of symptoms is less than 3 months
Chronic: if duration of symptoms is 3 months or more

Specify if:
With Delayed Onset: if onset of symptoms is at least 6 months after the stressor[1]

Source: American Psychiatric Association. 309.81 Posttraumatic Stress Disorder. In: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. American Psychiatric Association, Washington 1994:424-429

Understanding and describing the nature of trauma

"In the aftermath of systemic political violence, entire communities can display symptoms of PTSD, trapped in alternating cycles of numbing and intrusion, silence and reenactment. Recovery requires remembrance and mourning...Like traumatized individuals, traumatized countries need to remember, grieve, and atone for their wrongs in order to avoid reliving them."3 The parallel between individual and collective needs is often made by analysts and practitioners concerned about the implication of massive trauma on the capacity of any society to deal with the past and put a term to massive violence. "In responding to such trauma, groups and nations tend to function similarly to individuals. Societies shattered by the perpetration of atrocities need to adapt or design mechanisms to confront their demons, to reckon with these past abuses. Otherwise, for nations, as for individuals, the past will haunt and infect the present and future in unpredictable ways."4 If this concern is widely shared, the way to understand and describe it has been the subject of many debates among practitioners. As the USIP special report noted, following an inter-disciplinary seminar: "There is disagreement over whether medical approaches to diagnosing and treating posttraumatic stress disorder in individuals are relevant for transitional justice and reconstruction processes at the community and national levels. While we often use medical terms to describe 'wounded' societies and their 'recovery,' some believe that we should not psychopathologize the process of social reconstruction."5 Many authors have, for instance, denounced an abusive use of the terms of 'collective psyches' when dealing with nations. Many have stressed the fact that "...what is required psychologically for an individual to recover from trauma and be reconciled with the past (or with the perpetrator) need bear no resemblance to what might be required for a society to do so: the problems of war-torn societies cannot be reduced to the conflict interface between victims and perpetrators. As one move[s] from the interpersonal or inter-group or societal level, efforts to heal [a] relationship has an inevitable political dimension that is conspicuously downplayed, or even absent, from much of the reconciliation literature...Reintegration of combatants into the communities, for example, may increase the distress of their victims, with negative effects on their personal healing or local reconciliation, but may be vital for the goal of achieving societal reconciliation by removing a potential threat to peace."6

What remains at the core of the debate and largely under-explored is "how the relationship between individuals' mental states and personal attitudes affect the beliefs and behavior of the social group and larger societies of which they are part. A related issue is how intra- and inter-group relations affect the mental health of traumatized individuals."7

What is true at the diagnosis stage appears even clearer at the stage of designing action programs. "What may be effective at the societal level may harm individuals, and what may be effective at the individual level may harm the broader society. Further, what may be painful in the short-term may prove beneficial in the long-term."8 This is particularly true when looking at discourses and interventions dealing with 'reconciliation.' Nation-building discourses on reconciliation often subordinate individual needs to collective imperatives. "[...]Truth commissions and individual processes of healing work on different time lines. Calls for reconciliation from national leaders may demand too much psychologically from survivors, and retribution may be just as effective as reconciliation at creating symbolic closure...Nations do not have collective psyches which can be healed, nor do whole nations suffer post-traumatic stress disorder and to assert otherwise is to psychologize an abstract entity which exists primarily in the minds of nation-building politicians."9

Examining the meaning individuals and groups assign to violence

Another argument often made specifically by the advocates of a multidisciplinary approach is the importance of examining the meaning and significance that individuals and groups assign to the violence, in addition to standard medical and psychological variables. "These cultural factors require attention to the symbolic and social worlds within which people in post-mass-crime settings operate."10 This goes beyond the recognition of the importance of context and culture. Such an approach requires an understanding of the interaction between individual and collective rehabilitation, and therefore of the limits of psychiatric methods alone. Most of the research undertaken on that subject "focuses on one perspective or the other, in part because they are studied by different disciplines that do not conceptualize and focus their investigations in the same way."11 Significant progress has nevertheless been made in the last few years with empirical studies conducted in different countries, helping to better articulate these different dimensions and innovative interventions crafted by non-governmental organizations to assist individuals as part of a community network.12 An important argument made by those who strongly denounce the risk of "psychopathologizing" communities and societies, is the importance of focusing on the identification and strengthening of the sources of resilience within societies, rather than on their problems and multiple traumas. 13

Linking individual & community needs and resources in integrated approaches

In practice, most practitioners agree that individual and community dimensions must be addressed in integrated approaches and that it is important to go beyond false dichotomy. In other words, both trauma and psychosocial approaches need to be combined at different levels of intervention, depending on how affected a person or a group is by the violent conflict.14 The Inter-Agency Standing Committee (IASC) Task Force on Mental Health and Psychosocial Support Guidelinespresents a clear illustration of such an integrative approach.15

While many national government programs focus their efforts at healing individuals through counseling and mental health treatment, many other programs are working to assess both individual and community needs and devise strategies to address both as a means of healing. Most ethno-psychiatrists, for instance, would stress that "aid workers need to address the problems of groups and not just individuals who suffer in the wake of conflict, and beyond that, to structure a culturally-competent response to large-scale human suffering."16 In practice, organizations will engage the family and the local community in which individuals are embedded. This requires a good understanding of how those relationships are built in their particular context and building a sense of trust among the individuals involved.

Moreover, the needs and modalities for such linking may vary among countries and even from one community to the next, as exemplified by a comparative look at the situations of villages in Peru and Colombia. "When a local community consists of collective, functional units, as in some Peruvian villages, people have a tendency to not react solely with conventional PTSD symptoms, or to have the attitude that traumatic memory should be treated with crisis intervention. This is in contrast to some villages in Colombia where people are more individualistically oriented and reactions to trauma are more concerned with guilt and shame. In Peru, psychosocial work is carried out mostly by strengthening the construction of the local community, whereas in Colombia, individual psychological interventions are more widely used and accepted."17Psychologist Peter Elsass' study demonstrates that the concept of traumatic memory should be considered in both collective and individual aspects, depending on the nature of the underlying organization of society and culture.18

In many cases, there is also a high probability that war and violence have changed the way individuals think of themselves in relation to the group, and the forms and meanings of what 'community' is about. This means that the context must be carefully assessed before any intervention takes place. Such assessment is generally needed at a micro-level as situation can vary greatly from one community/group/village/neighborhood to another.

Specific methods are also needed to facilitate collective process. Jean-Clement Metraux, a psychiatrist who has developed a methodology for collective mourning, has identified different elements which may help construct group identity. He has also stressed the importance of recognizing that the group acquires an inviolable 'sacred' element, or areas of silence that outsiders have to respect. In the collective interviewing process, this space should be symbolized and ritualized at the beginning of each session.19

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Medicalizing trauma and healing the individual: The use of PTSD

A key and related debate is the degree of adequacy of Western psychiatric categories such as 'trauma' or Posttraumatic Stress Disorder (PTSD) in non-Western countries. PTSD refers to a behavioral/cognitive conceptualization of trauma that corresponds to a leading perspective in the field, at least in the West.

It is important to note that the majority of people who experience a traumatic event do not develop PTSD. Many have initial symptoms but most recover from any initial symptoms on their own. Also, it is important to emphasize that it is only when symptoms interfere with a persons daily functioning that they are considered to have PTSD (criterion F).20

This framework has been proved helpful as a diagnosis tool and in the development of clinical research. Many studies have shown evidence for the efficacy of various treatment approaches for PTSD and comprehensive sets of guidelines regarding treatment of this kind of disorder have been developed.21 Even when they approach the trauma differently, many specialists continue to use the PTSD language to describe the problems they address.

Frequently encountered challenges to the diagnosis and treatment of PTSD in post-conflict areas include illiteracy and the actual unavailability of psychotherapeutic treatment.22 But many practitioners point to more critical issues in the use of the PTSD model in the non-Western world. They believe that the characterization and terminology of PTSD in all post-conflict settings necessarily imposes a Western concept where it may not fit, medicalizes and individualizes trauma, and doesnt account for a collective experience of trauma or its relationship to social or cultural factors. A vast medico-anthropological literature "suggests that these categories are unable to encompass all the cultural and psychological meanings of trauma-related experiences in such environments; in particular they may omit the moral dimensions of suffering."23 Dr. Roberto Beneduce, ethnopsychiatrist, defines "the question of memory and trauma [as a] moral rather than medical or psychiatric issue."24 For many, "the medicalisation of 'trauma' individualizes and isolates suffering in the body against a cultural backdrop which advocates the individual 'management' of suffering. When trauma is medically mapped as emotional distress in the body it conceals the social contexts in which trauma is produced and the ways in which the personal legacies of trauma relate to social loss."25 Others argue that the PTSD framework should not be used in contexts where individuals and communities often experience multiple/prolonged trauma,26 joining the voice of those who stress the importance of the history of violence.27

Critiques of the PTSD model also question the tendency to medicalize what are political, cultural, economic, and psychosocial phenomena.28 "Those who argue against 'medicalizing' the focus of trauma relief suggest that reliance on terms such as 'trauma' and 'healing' divert attention away from the basic issue of how societies rebuild themselves after massive violence. From this perspective, the success or failure of those efforts depends primarily on establishing (or reestablishing) the rule of law and viable political institutions, security from violence, freedom of movement, access to unbiased information, economic and physical reconstruction, and the development of a quality educational system. All of these factors are likely to play a role in the restoration of individuals sense that they have control over their lives. Yet, arguably, while reconstruction along these lines is necessary to achieving stabilization and accountable government, fundamental psychological adjustments in individual and group identity-- aided by reconstruction processes-- are essential to reconciliation."29

Finally, the critics of an over medicalized approach of the issue denounce the emphasis on individual 'victims' as opposed to identification of individuals as 'survivors,' historical 'actors' in a struggle, members of families and communities.30 "More than an abstract concern, this way of seeing is directly linked to the identification and utilization of local resources."31

Psychosocial models to address war trauma beyond the PTSD model

Various conceptualizations of trauma that widen and expand the PTSD model have been proposed by different authors. Below are examples of three different psychosocial models:

Alastair Ager identifies tensions that underlie the debate of implementation of psychosocial interventions in war-affected populations: generalizability vs. uniqueness of relevant knowledge, valuing technical vs. indigenous understandings, planning of targeted vs. community-based interventions. His proposed psychosocial potential response model involves 4 phases:

1.Ensure minimal disruption of intact protective influences;
2. is aimed at reestablishment of protective resources;
3. provision of compensatory support;
4. targeted therapeutic intervention.

The proposed model suggests that psychosocial programs begin with an explicit influence on unique, indigenous understandings and community-based support, and move toward more generalizable, technical understandings and targeted support only when evidence suggest that this is appropriate.

Source: Alastair Ager. Tensions in the psychosocial discourse: implications for the planning of interventions with war-affected populations, Development in Practice 7 no 4 (1997):402-7.

Derrick Silove stresses the fact that the nature of modern warfare is such that whole populations are at risk of suffering extensive trauma, injustices, loss, and displacement. He examines whether contemporary notions of trauma, with special focus on the category of post-traumatic stress disorder (PTSD), are adequate in assessing the multiple effects of such experiences. He suggests that a focus on intervening psychosocial adaptive systems may assist in delineating more clearly the pathways that determine whether traumatized persons achieve psychosocial restitution or are at risk of ongoing psychiatric disability. A model is proposed which suggests that torture and related abuses may challenge five core adaptive systems subserving the functions of safety, attachment, justice, identity-role, and existential-meaning. He argues that a clearer delineation of such adaptive systems may provide a point of convergence that may link research endeavors more closely to the subjective experience of survivors and to the types of clinical interventions offered by trauma treatment services.

Source: Derrick Silove. The Psychosocial Effects of Torture, Mass Human Rights Violations, and Refugee Trauma: Toward an Integrated Conceptual Framework. The Journal of Nervous and Mental Disease 187 no. 4 (1999): 200-207

Marta Cullberg Weston proposes a model aimed at:
(1) Individual healing of inner wounds;
(2) Rebuilding safety, trust and social connectedness in the local community;
(3) Macro-level reconstruction of society with its impact on healing;
(4) Work towards reconciliation between ethnic groups.

Source: Marta Cullberg Weston, A Psychosocial Model of Healing from the Traumas of Ethnic Cleanising:
The Case of Bosnia (The Kvinna Till Kvinna Foundation: 2001)

Go to Case study: Guatemala: A culturally embedded use of PTSD as a diagnostic tool
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Psychosocial responses within the context of culture

Many practitioners and scholars alike stress the need to widen the concept of trauma to adjust it to the local cultural dynamics of the people both for the understanding of the cultural meaning of the trauma itself (to address the role of culture in PTSD) and in defining strategies that can actually support healing processes.

Cultural understandings of trauma

"Trauma has been conceived of as an event (of a short or longer duration) that is outside the range of usual human experience and that would be markedly distressing to anyone. This conception suggests that the individual, regardless of his or her cultural environment can suffer, in some way, negative psychological consequences when confronted with overwhelming experiences. Such a definition can be problematic when trauma is discussed from a cultural perspective. This conceptualization of trauma based on Western biomedicine and Western Psychoanalysis becomes too narrow and restricted for the discussion of trauma and posttraumatic experiences from a cross-cultural dimension."32 In particular, some practitioners strongly recommend avoiding "the use of Western quantitative research instruments which are not based on culture-specific qualitative data [...]. This lack of cultural validation of instruments perpetuates the so-called category fallacy, in which indigenous diagnoses are overlooked and Western categories imposed where they have no cultural validity."33

"The processes of closure and healing-- psychological and medical concepts that are used most often in reference to individuals rather than communities-- are poorly understood when they are used to describe social dynamics in societies emerging from violent conflict. It is difficult to define these processes in practical or quantifiable terms and problematic to apply them to widely different cultures."34 Studies of war-affected populations in Mozambique, for instance, have shown that talking about traumatic experiences does not necessarily help patients come to terms with their distress. "In Mozambique, trauma is perceived as a collective affliction affecting individuals and living and dead relatives. Healing trauma involves spiritual mediums, purification rituals, and venerating the spirits."35

Such techniques may prove significantly more effective and emphasize that "it is not possible to respond to the different needs of the victims and survivors of mass crime if one does not understand the local forms and logic of social ties, their transformations and the manner in which local actors have tried to survive and understand mass violence: their cultural strategies of dealing with death, mourning and suffering."36 Advocates of this view also emphasize the need to have a clear sense of each particular context. "This is important because when the subject recounts the unfolding of an event on the backdrop of what she/he considers to be the normal order of things, it means that she/he relates what makes up a psychic event or a trauma. Bruner also emphasized the use of rhetorical figures. Far from being useless ornaments, figurative speech describes the scope of the latent possibilities the narrator could employ to describe the context that, in turn, makes the event readable. Moreover, listening to the subjective dimension of the account tells us what actually made it an event for the speaker."37 In some cases, ethno-psychiatrists notice that "it makes little sense to speak of violence or of trauma in the psychiatric sense, outside precise social contexts."38 Dr. Roberto Beneduce poses this diagnosis in relation with the direct participation of children and adolescents in conflicts. Based on different field studies, he argues that this participation does not always and necessarily implies psycho-pathological effects or damage. Such diagnosis is, of course, crucial when deciding the kind of programs needed for the reintegration of former child soldiers.39

Contextualizing interventions

It is essential for those working in post-conflict societies to fully grasp the nature of the conflict, which includes the roles of victims/survivors, perpetrators, and observers.40 Indeed, "without contextual insight, it is difficult to mobilize resources and help people cope with the horrors that come from armed conflicts, human rights violations or other types of disasters."41 As emphasized by the Transcultural Psychosocial Organization (TPO) multi-site transcultural mental health program, the effectiveness of interventions depends on studying the cultural variables and the context in which behavior occurs on both the population and on the individual level, in order to understand normal and deviant behavior.42

This also requires an understanding of the long-term historical context in which the more recent violence occurred. This dimension is particularly important given the intergenerational aspects of trauma. It is also why many programs work in close relation with schools and programs aiming at dealing with collective memories of violence. Go to Reconciliation and Memorialisation, Historiography and History Education

Cultural competence for interventions

Knowledge of local cultures and cultural sensitivity are even more important for outsiders involved in the design and/or implementation of intervention strategies. "Some societies have indigenous traditions, such as customary law practices or traditional healing rituals that may be more effective in promoting individual and social recovery and reconstruction than legal or medical solutions imported from the West."43

For example, while Western approaches to trauma rely primarily on 'verbalized remembering,' some traditional societies have nonverbal methods for expressing and addressing trauma.The extent to which a narrative process can be used in the therapy is a critical point. Some forms of psychotherapy for traumatized children and adolescents have been developed, based on what is called "Narrative Exposure Therapy," a short-term treatment method for traumatized adults. This treatment has been specifically designed and experienced with refugees in relation with war trauma.44 Such an approach tends to be criticized by ethnopsychiatrists who stress the importance of silence as a sign of respect in some cultures and the value of nonverbal approaches.45

Ethnopscychiatric research also "indicates that local healing strategies and cultural conceptions of death or mourning represent a useful ('therapeutic') tool for individuals or communities affected by traumatic experiences. Unfortunately, international teams of experts have sometimes ignored or underestimated these kinds of local resources. They are usually put under the disputable label of 'harmful traditional practices.' Nevertheless, the so-called 'traditional healers' constitute a potential resource to cope with fear, uncertainty and 'pollution' concerns that mark people's experiences during and after war in many African or Asian countries. [...] Community-based rehabilitation should take into consideration these spontaneous resources for another reason as well: the language and the ideology of local healers or other social actors, apart from controversial uses sometimes described in the literature, are largely shared by the population and can therefore assist in reconstituting a common perspective" in post-war contexts; 46 field research undertaken by ethnopsychiatrists such as Dr. Roberto Beneduceand Dr. Maurice Eisenbruch is very revealing of the shared ideologies and benefits attributable to local healers. While it hasn't always been the case, in guidelines for dealing with mental health and psychosocial interventions for trauma, an emphasis is now increasingly put on addressing cultural dimensions, particularly in training as this is also an element of rapid cultural change in society.47

The importance of cultural trauma

Last but not least, an interest in the local culture is important also because, in most contemporary wars, the culture itself, the "possibility of social life" has been under attack.48 This, in itself, calls for a broader conceptualization of trauma "in which the loss or disintegration of cultural beliefs and values should be considered as traumatic experience too."49 Indeed, "the religious, cultural and symbolic dimensions of the trauma can be as important as the more objective ones, since they are both factual and immediate, such as with the disappearance or death of a loved one, or the experience of torture. Furthermore, in Guatemala and Cambodia alike, the genocidal project had the declared intention of destroying a culture and a history. In the narratives of victims and survivors, these aspects form an integral part of the violation of their rights and their emotional experience."50 The disruption of the symbolic order includes elements such as the loss of media for transmitting traditions or the repetitive transgression of taboos. In Peru, Kimberly Theidon, an anthropologist who has worked in the highlands of Ayacucho where most of the killings and disappearances occurred during the internal war from 1980 to 2000, "shows how much war was interpreted but even more experienced concretely as an attack against cultural practices and the very meaning of what it means to live as a human being in these villages."51

In other words, the legacy of violence is not merely evidenced through the psychological symptoms of the individual victim, but operates as well at a social, cultural and psychosocial level. "Atrocity is a politics of affectivity that deploys the victim dead, mutilated or traumatised as a seductive and terrifying event. It overturns the habitual (normative) in order to reconstitute social relations and meaning."52 The experience of loss and death must be relived through naming and mourning, through its socialization. Michael Humphrey, Professor at the University of New South Wales, puts forth an analysis that reinforces the importance of understanding the impact and methods to deal with political violence contextually. As such, the solution to dealing with massive trauma lies within addressing its legacy in the social fabric and the biopolitics of society.53

Such an approach may also actually bring hope. Cultural trauma, when recognized, may point to directions for peace-building. Sociologist Jeffrey C. Alexander suggests that cultural trauma, and an understanding of trauma at a collective level, may precipitate action: "Social groups, national societies, and sometimes even entire civilizations not only cognitively identify the existence and source of human suffering but 'take on board' some significant responsibility for it. Insofar as they identify the cause of trauma, and thereby assume such moral responsibility, members of collectivities define their solidarity relationships in ways that, in principle, allow them to share the sufferings of others."54

How to Choose Traditional Healers to Work with You:

A WHO guideline about mental health and refugees

Doctors, nurses and missionaries have often opposed traditional healers and have tried to stop their practices. Because of this, people in the refugee community may tell you that there are no traditional healers among them. They want to protect their healers. The healers also may be afraid to talk to you. Reassure them that you do not wish to stop them working among their people.

Explain to the community leaders and the people why you wish to cooperate with the traditional healers. Tell them what your intentions are. Say that you want to help the healers so that they can use their skills for treating people. Say that you think that both traditional and scientific medicines are good and can get along well together.

Ask to meet several healers, not just one. Tell them about your plans and how you would like to work with them. Listen to their ideas. Always let them see that you believe their work is important and that you respect them.

Do not work with only one healer. Always have several working with you. The risk in working with only one is that he or she may be a quack who is interested only in power and fame. Even a healer who is genuine may become too proud and take risks to get more glory. Also the other healers will probably become jealous and may try to give your chosen healer a bad reputation among the people. Several healers working together as a group can watch each others activities. If one of them may try to do things that may harm the groups reputation, the others will probably prevent it.

Always insist that the healers fulfill their role responsibly. This means not only caring for people in the best way. The healers must also give others especially doctors and nurses a good image of their medicine and of themselves. Because of this they should not take risks in treating people who are very sick or dangerously ill. Explain to the healers that it is better to send people who are extremely ill to the medical doctors if possible. Say that if a person dies in the hospital people will think that the death resulted from the illness. But if the person was treated by traditional healers, medical doctors may say that the healers caused the death. Stress that this would harm their reputation.

Source: WHO, Mental Health and Refugees. 1996

Using local cultural resources and 'traditional' healing methods

Most guidelines for dealing with mental health and psychosocial interventions for trauma now emphasize the need to address cultural dimensions, particularly in training. When trying to implement such recommendations, practitioners may face a number of key challenges which have to do with the way those resources are identified and used.

The extent of cultural sensitivity is still the subject of debates. While some focus heavily on the importance of understanding trauma within the cultural discourse of the particular society,55 others understand context to be important but also recognize that it is necessary to avoid "essentializing or romanticizing culture."56 Some models suggest "that psychosocial programs begin with an explicit influence on unique, indigenous understandings and community-based support, and move toward more generalizable, technical understandings and targeted support only when evidence suggest that this is appropriate."57 The Transcultural Psychosocial Organization (TPO) model uses "a methodology which captures the idiomatic description of mental health problems that fit local cultural illness experiences in order to bolster indigenous coping strategies. Each project in the different countries develops its own culture-specific approach within this general outline or blueprint." 58
Go to Traditional and Informal Justice Systems
One key issue has to do with who decides what the local cultural resources and norms are and presents them to outsiders. Outsiders need to be especially vigilant in that assessment and put in place processes that allow such identification and find ways to discussed these at the community level. Some of the local 'cultural resources' may have also been tainted in the process of war and they must be subjected to scrutiny by communities seeking to re-assert a reality that is not war-based. Without some outside tools and perspectives, "local communities may remain trapped in the power of war-based structures of thought, with little to move them to another perspective."59

There is a risk of co-optation by dominant forces in a community along political and gender lines. This is particularly important when identifying and choosing traditional healers to work with. Because they are more familiar to the local populations and easier to access, traditional healers are often more immediate and comfortable means for people to resolve personal issues. But their role and status in the local community may have changed during the course of the conflict. Moreover, as stressed by Dr. Maurice Eisenbruch, a strong advocate of 'cultural competence in international health,' "not all healers-- like not all psychiatrists-- are equally capable of offering effective assistance."60 Indeed, in some contexts, the recourse to so-called traditions may actually appear as an obstacle to any transformation process in the community. This may in part explain that these cultural strategies are not always able to help victims as exemplified by the case of rape and violence against women in Democratic Republic of Congo.61

At the same time, however, the 'invisible,' including women, children, and the elderly, are often re-creating their own coping strategies and cultural products and projects in the more hidden sectors of cultural life. These often incorporate the artistic dimensions of everyday life, including artisanship, work songs, prayers and narratives. They include rituals from birthing to burial. In these realms, the culture is both re-instituted hopefully along non-violent lines, and women and other disempowered groups proceed to take back a degree of subjectivity and self-empowerment.62 The role of outsiders is then to allow these strategies a space to develop.

"In order to work in communities at a level that is appropriate, the matter of insider and outsider knowledge must become a dialogical exchange in the hands of the local community. [...] In particular, a community can make use of the discoveries of other cultures, that have themselves experienced violence, and of global efforts to comprehend how best to move from the structures and perceptions of mass crime and mass violence to those of the mundane and peaceful. Yet it can only effectively do so by combining the inner and outer perspectives into a new synthesis that is local by nature."63

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Evaluating mental health programs

Although there have been attempts to examine the various effects of trauma-related mental health and psychosocial treatments, many have been criticized for their lack of methodological rigor. Without well-controlled and randomized studies, critics argue that the efficacy of many of these mental health or psychosocial interventions remains unknown. While in other areas of health intervention scientific research tends to precede and influence practices on the ground, the reverse trend can be observed amongst psychosocial methods in emergency situationsUnderlying the problem of insufficient data to guide future interventions is the difficulty involved in designing reliable and valid instruments by which to accurately assess psychosocial wellbeing. Furthermore, the lack of an evidence base for interventions in non-Western disaster and conflict settings means that most practical guidance tends to be based on expert and staff opinion and experience...64

The situation has led to an increasing call to improve standards and strengthen the evidence base for this field. There have been recent efforts to develop consensus policy derived from best practice for emergency psychological and social interventions (e.g. the SPHERE standards project,65 the Inter-Agency Standing Committee (IASC) Task Force on Mental Health and Psychosocial Support Guidelines, 66 and the guidelines by the International Society for Traumatic Stress Studies (ISTSS) Taskforce on International Trauma Training).67 Guidelines such as these have stressed the need for ongoing monitoring and evaluation practices not only to inform planning and policy, but to strengthen the evidence base for psychosocial and mental health interventions.68

Among the key pending questions are: what are the main "healing agents" and how do they interact? What does contribute to healing and why? What are the pre-requirements for psyscho-social recovery? What are the main impediments? While more analyses have been published along those lines, few empirical elements are available to help understand how individual and communal healing proceed, what can support them at best, and how they can be best monitored and assessed.69

One specific difficulty is linked to the fact that "the long-term outcome of programs is often primarily determined by the original design. This is not realistic with a view to the major changes that may occur among the target population."70 This means that monitoring and evaluation tools need to also address contextual evolutions that may affect the psychosocial wellbeing of local populations, in particular in terms of security, as the maintenance of daily insecurity is often one major source of mental distress.

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1. A. Ager, "Tensions in the psychosocial discourse: implications for the planning of interventions with war-affected populations," in Development in Practice 7, no. 4 (1997), 30.
2. Hugo Van Der Merwe and Tracy Vienings, "Coping with Trauma," in Peacebuilding: A Field Guide, edited by Luc Reychler and Thania Paffenholz, 343-351 (Boulder, CO: Lynne Reinner Publishers, Inc., 2001), 343.
3. Judith Herman, Trauma and Recovery: The Aftermath of Violence - From Domestic Abuse to Political Terror (New York: Basic Books, 1992), 242.
4. Neil J. Kritz, "Coming to Terms with Atrocities: A Review of Accountability Mechanisms for Mass Violations of Human Rights," in Law & Contemporary Problems 59, no. 127(Autumn 1996).
5. Judy Barsalou, Trauma and Transitional Justice in Divided Societies Special Report 135 (Washington DC: US Institute of Peace, April 2005).
6. Ann-Sofi Jakobsson Hatay, "Peacebuilding and Reconciliation in Bosnia, Herzegovina, Kosovo and Macedonia 1995-2004" (Uppsala, Sweden: Uppsala University Department of Peace and Conflict Research, 2005), 61.
7. Judy Barsalou, "Managing Memory: Looking to Transitional Justice to Address Trauma," in Peacebuilding in Traumatized Societies, Barry Hart, ed. (Lanham, MD: University Press of America, 2008); 30 and Personal communication with the author, September 1, 2008; See also Jody Halpern and Harvey M. Weinstein, "Rehumanizing the Other: Empathy and Reconciliation," Human Rights Quarterly 26, no. 3 (2004): 561-583.
8. Barsalou, Trauma and Transitional Justice in Divided Societies, 9.
9. Brandon Hamber and Richard Wilson, "Symbolic Closure through Memory, Reparation and Revenge in Post-Conflict Societies," Journal of Human Rights 1, no. 1 (March 2002).
10. Batrice Pouligny, Simon Chersterman, Albrecht Schnabel, eds., After Mass Crimes: Rebuilding States and Communities (New York: United Nations University Press, 2007), 5.
11. Ibid.
12. See in particular the results of ethnographic studies published in Pouligny, et al., After Mass Crimes: Rebuilding States and Communities.
13. Barsalou, Trauma and Transitional Justice in Divided Societies.
14. Communication with Jeannie Annan, July 14, 2008.
15. World Health Organization. The Inter-Agency Standing Committee (IASC) Task Force on Mental Health and Psychosocial Support Guidelines. Geneva: The Inter-Agency Standing Committee, 2007.
16. Maurice Eisenbruch, "The Uses and Abuses of Culture: Cultural Competence in Post-Mass-Crime Peace-Building in Cambodia," in Pouligny, et al., After Mass Crime: Rebuilding States and Communities, 71-96.
17. Peter Elsass, "Individual and Collective Traumatic Memories: A Qualitative Study of Post-Traumatic Stress Disorder Symptoms in Two Latin American Localities," Transcultural Psychiatry 38, no. 3 (2001): 306-316.
18. Ibid.
19. Batrice Pouligny, Bernard Doray and Jean-Clment Martin, "Methodological and ethical problems: A trans-disciplinary approach," in Pouligny et al., 26; see also Jean-Claude Metraux, Techniques pour llaboration des deuils collectifs, Re-imagining Peace after Massacres Project.
20. Communication with Jeannie Annan, July 14, 2008.
21. Edna B. Foa, Terence M. Keane, and Matthew J. Friedman, eds., Effective Treatments for PTSD: Practice Guidelines from the International Society for Traumatic Stress Studies (New York: Guilford Press, 2000).
22. Christine Knaevelsrud, Birgit Wagner, Anke Karl, and Julia Mueller, "New Treatment Approaches: Integrating New Media in the Treatment of War and Torture Victims," Torture 17, no. 2 (2007): 76-78.
23. Pouligny, et al., After Mass Crimes: Rebuilding States and Communities, 6.
24. Ibid. See also in that volume: Roberto Beneduce, "Contested memories: Peace-building and community rehabilitation after violence and mass crimes-- A medico-anthropological approach," 41-70.
25. Michael Humphrey, "From Terror to Trauma: Commissioning Truth for National Reconciliation," Social Identities 6, no. 1 (2000), 7.
26. P. Bracken, J. Giller, D. Summerfield, "Psychological Responses to War and Atrocity: the Limitations of Current Concepts," in Social Science and Medicine 40 (1995): 1073-82.
27. Beneduce, "Contested memories: Peace-building and community rehabilitation after violence and mass crimes- A medico-anthropological approach."
28. M. Brinton Lykes and Marcie Mersky, "Reparations and Mental Health," in The Handbook of Reparations, ed. Pablo De Grieff, 589-622 (New York: Oxford University Press, 2006).
29. Barsalou, Trauma and Transitional Justice in Divided Societies.
30. Lykes and Mersky, "Reparations and Mental Health;" Pouligny, et al., After Mass Crimes: Rebuilding States and Communities, 3.
31. Pouligny et al., Ibid.
32. Victor Igreja, B.J.N. Schreuder, W.C. Kleijn, "The Cultural Dimensions of War Traumas in Central Mozambique: The Case of Gorongosa," Transcultural Psychiatry 40 (2003): 460-487.
33. "Outline of TPOs Public Mental Health Model for Massive Traumatization," Transcultural Psychosocial Organization.
34. Ibid.
35. Alcinda Honwana, "Sealing the past, facing the future: trauma healing in rural Mozambique." Accord (1998).
36. Beatrice Pouligny, Simon Chesterman and Albrecht Schnabel, "Introduction: Picking Up the Pieces," in Pouligny, et al., After Mass Crimes: Rebuilding States and Communities, 2-3.
37. Pouligny, et al., "Methodological and ethical problems: A trans-disciplinary approach," 28.
38. Beneduce, "Contested memories: Peace-building and community rehabilitation after violence and mass crimes A medico-anthropological approach," 55.
39. Ibid.
40. Lykes and Mersky, "Reparations and Mental Health;" Ervin Staub, "Reconciliation after Genocide, Mass Killing, or Intractable Conflict: Understanding the Roots of Violence, Psychosocial Recovery, and Steps toward a General Theory," Political Psychology 27, no. 6 (2006).
41. Joop de Jong, ed., Trauma, War, and Violence: Public Mental Health in Socio-Cultural Context (New York: Kluwer Academic/Plenum Publishers, 2002).
42. "Outline of TPOs Public Mental Health Model for Massive Traumatization."
43. Barsalou, Trauma and Transitional Justice in Divided Societies.
44. Elisabeth Schauer, Frank Neuner, Thomas Elbert, Verena Ertl, Lamaro P. Onyut, Michael Odenwald & Maggie Schauer, "Narrative Exposure Therapy in Children: A Case Study," Intervention 2, no. 1 (2004): 18-32.
45. Barsalou, Trauma and Transitional Justice in Divided Societies.
46. Beneduce, "Contested memories: Peace-building and community rehabilitation after violence and mass crimes A medico-anthropological approach," 43; see also Eisenbruch, "The Uses and Abuses of Culture: Cultural Competence in Post-Mass-Crime Peace-Building in Cambodia."
47. Stevan Weine, Yael Danieli, Derick Silove, Mark Van Ommeren, John A. Fairbank, Jack Saul, for the Task Force on International Trauma Training of the International Society for Traumatic Stress Studies, "Guidelines for International Training in Mental Health and Psychosocial Interventions for Trauma Exposed Populations in Clinical and Community Settings," Psychiatry 65, no. 2 (Summer 2002).
48. Pouligny, et al., "Methodological and ethical problems: A trans-disciplinary approach," 20.
49. Igreja, et al., "The Cultural Dimensions of War Traumas in Central Mozambique: The Case of Gorongosa."
50. Ibid, 37.
51. Ibid, 11; see also Kimberly Theidon, "Intimate enemies: Reconciling the present in post-war communities in Ayacucho, Peru," in Pouligny et al., After Mass Crimes: Rebuilding States and Communities.
52. Michael Humphrey, The Politics of Atrocity and Reconciliation: from Terror to Trauma (London: Routledge, 2000), 79.
53. Brandon Hamber, "The Burgeoning Field of Transitional Justice," review of The Politics of Atrocity and Reconciliation: from Terror to Trauma, by Michael Humphrey, TRN-Newsletter 2, Hamburg Institute for Social Research, June 2004.
54. Roberta Culbertson and Batrice Pouligny, "Re-imagining peace after mass crime: A dialogical exchange between insider and outsider knowledge," in Pouligny et al., After Mass Crimes, 278. See also Jeffrey C. Alexander, The meanings of social life: A cultural sociology (New York: Oxford University Press, 2003), 85. See especially chapter 3, "Cultural trauma and collective identity," 85108.
55. Maurice Eisenbruch, "From Post-Traumatic Stress Disorder to Cultural Bereavement: Diagnosis of Southeast Asian Refugees," Social Science and Medicine 33, no. 6 (1991).
56. Pouligny, et al., "Introduction: Picking Up the Pieces," 3.
57. Ager, "Tensions in the psychosocial discourse: implications for the planning of interventions with war-affected populations," 30.
58. "Outline of TPOs Public Mental Health Model for Massive Traumatization."
59. Culbertson and Pouligny," Re-imagining peace after mass crime: A dialogical exchange between insider and outsider knowledge," 283.
60. Eisenbruch, "The Uses and Abuses of Culture: Cultural Competence in Post-Mass-Crime Peace-Building in Cambodia," 73. See also Yael Danieli, "Multicultural, multigenerational perspectives in the understanding and assessment of trauma," in The Cross-Cultural Assessment of Psychological Trauma and PTSD, J.P. Wilson & C. Tang, eds., 65-89 (New York: Springer-Verlag Publishers, 2007).
61. Beneduce, "Contested memories: Peace-building and community rehabilitation after violence and mass crimes A medico-anthropological approach," 57.
62. Culbertson and Pouligny, "Re-imagining Peace After Mass Crime: A Dialogical Exchange Between Insider and Outsider Knowledge," 281-284.
63. Ibid, 285.
64. "Improving the Outcome Research on Mental Health and Psychosocial Programs in Post-Disaster and (Post)Conflict Settings," an Issues Paper for the CRED/EM-SEANET Expert Consultation, Bangkok, Thailand, 26-27 October 2006, 4-5.
65. The Sphere Project was launched in 1997 by a group of humanitarian NGOs and the Red Cross and Red Crescent movement. Sphere is based on two core beliefs: first, that all possible steps should be taken to alleviate human suffering arising out of calamity and conflict, and second, that those affected by disaster have a right to life with dignity and therefore a right to assistance. The project has developed several tools, the key one being the handbook. For more information see "The Sphere Project: Humanitarian Charter and Minimum Standards in disaster Response."
66. The IASC Taskforce on Mental Health and Psychosocial Support was formed in June 2005 to develop inter-agency guidance for field-testing along the lines of the IASC Guidelines for HIV/AIDS Interventions in Emergency Settings. The Task Force is co-chaired by the World Health Organisation and the NGO consortium InterAction. For more information see "IASC Reference Group on Mental Health and Psychosocial Support in Emergency Settings," Inter-Agency Standing Committee.
67. The International Society for Traumatic Stress Studies (ISTSS) created a Task Force on International Trauma Training in November 1999 to address an important activity of trauma mental health professionals. International trauma training refers to the training initiatives by professionals with expertise in trauma mental health who travel from one country to another in the effort to teach and train local persons to respond better to trauma-related problems. The overall goal of the Task Force is to advance international trauma training as it is currently being practiced. In an effort to work towards this goal, the Task Force began to draft Guidelines on International Trauma Training during its meeting of July 27 to July 30, 2000, in Chicago, U.S.A. The current version of the guidelines address four specific areas: (chapters accessible online) 1. The values underlying international trauma training 2. Contextual challenges in post-conflict societies 3. Core curricular elements 4. Monitoring and evaluation of training.
68. "Improving the Outcome Research on Mental Health and Psychosocial Programs in Post-Disaster and (Post)Conflict Settings," 4-5.
69. Communication with Dr. Simone Lindorfer, June 25, 2008.
70. "Outline of TPOs Public Mental Health Model for Massive Traumatization."

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