Searching for Normal in the Wake of the Liberian War. Sharon Alane Abramowitz
a process of symbolization of speech, or talk therapy, that reveals the traumatic experience or event and resynthesizes the traumatic event in a person’s life history. Adherents to cognitive approaches to trauma emphasized that the constant, routinized, conscious repetition of healthy practices and behaviors was necessary to create the context for the resolution of the traumatic response. Through careful instruction in correct behavior, substantial individual self-work by the trauma sufferer, constant vigilance and monitoring, and the provision of social support, specific behavioral modifications and conscious psychological adaptations could improve overall functioning, and resolve critical symptoms of impairment (i.e., auto-arousal, social withdrawal, flashbacks, panic attacks, and aggressive impulses). In order to breach the divide between the vernacular usages of trama and expatriate models, Liberian NGO workers in psychosocial and trauma-healing programs often attempted to integrate moral exhortation, talk therapy, behavior change, and social critique, thereby engaging in a pidgin psychiatry that hybridized both approaches in the grounded locales of humanitarian projects (Abramowitz 2010).
But what did trauma and, by extension, its healing or rehabilitation, mean in the world of humanitarian aid? What was promised, and what was delivered? (See Table 1.) Humanitarian practitioners became renowned in Liberia and internationally for overlooking key concepts, definitions, ethical frameworks, and cultural sensitivities in the rush to provide psychosocial intervention to war-affected populations. Consequently, around the end of the Liberian War, these very questions were attracting expert attention, and widespread critique. In an effort to develop minimum standards of response for mental health and psychosocial intervention in humanitarian contexts, leading humanitarian NGOs, UN agencies, and humanitarian funding institutions collaborated to establish a minimum set of guidelines for mental health and psychosocial interventions in humanitarian crises. The results of this multiyear endeavor, the Inter-Agency Standing Committee’s (IASC) Guidelines on Mental Health and Psychosocial Support in Emergency Settings, offered the following definition:
Table 1. Modes of Psychosocial Intervention
| Psychiatric Treatment Individual and Group Trauma Counseling Ex-Combatant Rehabilitation and Reintegration Gender-Based-Violence Counseling Conflict Resolution and Peacebuilding Education Community Reconciliation Initiatives Case Management Strengthening Social Structures and Relationships Ethnopsychiatric Interventions with Local Healers Community-Based Human Rights Education Play, Drama, Music, and Art Therapies Drug and Alcohol Rehabilitation |
The composite term mental health and psychosocial support is used in this document to describe any type of local or outside support that aims to protect or promote psychosocial well-being and/or prevent or treat mental disorder. Although the terms mental health and psychosocial support are closely related and overlap, for many aid workers they reflect different, yet complementary approaches.
Aid agencies outside the health sector tend to speak of supporting psychosocial well-being. Health sector agencies tend to speak of mental health, yet historically have also used the terms psychosocial rehabilitation and psychosocial treatment to describe non-biological interventions for people with mental disorders. Exact definitions of these terms vary between and within aid organizations, disciplines, and countries. As the current document covers intersectoral, inter-agency guidelines, the composite term mental health and psychosocial support (MHPSS) serves to unite as broad a group of actors as possible and underscores the need for diverse, complementary approaches in providing appropriate supports. (IASC 2007)
In this definition, the meanings of mental health, trauma healing, and psychosocial disorders, as well as the scope of their interventions, are obscure. Its vagaries are consistent with the humanitarian “gray literature” on trauma healing and psychosocial interventions. In these documents, the phrase “psychosocial interventions” refers to a set of rehabilitative practices that enable a process of healing by facilitating conditions for individuals to resume normal, everyday lives within their families and communities. It also, however, refers to individual, communal, and mass education campaigns to facilitate individual rehabilitation, community peacebuilding, and mass buy-in to the project of humanitarian transition.
Some greater definitional specificity can be gleaned from the operational definitions for mental health, trauma, and psychosocial disorders offered by the World Bank. According to the World Bank, mental health is simply the state of health as defined by the World Health Organization (WHO) (see Table 2). Mental illness includes any disorders of cognition or emotion recognized by Western psychiatry’s diagnostic conventions, which poses a clear problem of validity in non-Western contexts (de Jong 2002; Desjarlais et al. 1995; Kleinman 1980). Psychosocial disorders include any problems resulting from the interaction between the self, social conditions, and society. Better understood as “social suffering” in anthropological analysis (Kleinman, Das, and Lock 1997), the term “psychosocial” embraces the social attenuation that results from chronic exposure to violence, displacement, poverty, and injustice, but it can also be understood as the simple absence of mental health. Trauma is recognized as the vernacular expression of PTSD, or the medicalized expression of posttraumatic psychopathology, which often co-occurs with other forms of mental illness, as well as with problems surrounding social performance and social reintegration.
The concept of the “cycle of violence” has also gained traction among humanitarian experts, healthcare professionals, and mental health specialists. Many expatriates working in humanitarian intervention now believe that conflicts are caused by cyclical cultural and psychological forces that compel individuals to reproduce relations of violence ad infinitum. According to the cycle-of-violence thesis, people who have been affected by violence are moved to reproduce violence in the role of perpetrators or victims; this leads to a dynamic of socialization in which relations of violence become normative and cyclical (Herman 2001, Steinmetz 1977). Thus, the presence of violence in everyday life is presumed to predispose people to a cyclical repetition of violence through time.
Table 2. World Bank Definitions of Postconflict Mental Health
| Mental Health | “Mental health is more than the absence of disease or disorder. It is defined as a state of complete mental wellbeing including social, spiritual, cognitive and emotional aspects” (Baingana and Bannon 2004, 2). |
| Mental Illness | “A mental illness is a disorder of the cognition (thinking) and/or the emotions (mood) as defined by standard diagnostic systems such as the International Classification of Disorders, 10th Edition (ICD 10) or the American Psychiatric Association’s Diagnostic and Statistical Manual, Revised 4th Edition (DSM IV-R)” (Baingana and Bannon 2004, 2). |
| Psychosocial Disorders | “Psychosocial disorders relate to the interrelationship of psychological and social problems, which together constitute the disorder. The term psychosocial is used to underscore the close and dynamic connection between the psychological and the social realms of human experience. Psychological aspects are those that affect thoughts, emotions, behavior, memory, learning ability, perceptions and understanding. Social aspects refer to the effects on relationships, traditions, culture and values, family and community, also extending to the economic realm and its effects on status and social networks. The term is also intended to warn against focusing narrowly on mental health concepts (e.g., psychological trauma) at the risk of ignoring aspects of the social context that are vital to wellbeing” (Baingana and Bannon 2004, 2). |
| Needs | “The term ‘needs’ is used to describe the need for humanitarian or development interventions to bridge the gap between identified deficits and the envisioned future (short-term post recovery) situation of a sector or country” (Kievelitz et al. 2004). |
| PTSD |
A syndrome of symptoms meeting the criteria for posttraumatic stress disorder (PTSD) as specified by the American Psychiatric Association’s Diagnostic and Statistical Manual’s |