Psychosocial and economic support can be mutually enabling in working with highly vulnerable populations — but only if development practitioners start from a position of seeking information rather than defining a situation.
Livelihood work with war- and conflict-affected populations — where individuals often have ‘invisible wounds’ — must be holistic, humble and requires a healthy mix of psychosocial and economic interventions, Michael Wessells, professor of clinical population and family health at Columbia University, said on Tuesday during a World Bank panel discussion entitled “Invisible wounds: Improving development outcomes through psychosocial support,” where participants discussed how understanding local narratives and making these links can better allow for targeted support.
Development practitioners are widening the lens on livelihood work to see it as more than the means of securing the necessities of life. The work, in fact, must tie to physical, psychological, emotional and spiritual aspects of life as well, according to Joanna de Berry, a World Bank senior social development specialist for Eastern Europe and Central America.
The oft-prevailing sense of livelihood at the bank, though, is one where improved income is intrinsically tied to improved livelihood; and the road to “improved” is one through increased financial assets and resources.
But “there’s far more going on,” said De Berry.
Trauma creates new narratives, but support must acknowledge the past
Trauma-sensitive livelihood programs are critical when traumatic experiences have redefined family relationships, which in turn changes larger community dynamics.
And trauma can impact the way individuals think of themselves in relation to a group, affect civic trust and create confusion especially if cultural symbols were targeted, noted Beatrice Pouligny, independent researcher and senior consultant at the United States Institute of Peace.
It’s important to grasp the local understanding of local trauma and responses, she added, in order to be able to address the future and the stigma that often haunts victims and perpetrators after violence.
There was a time that people thought of trauma in terms of a ‘rubber band effect,’ explained Richard Mollica, professor of psychiatry at the Harvard Medical School.
“In 1981, we didn’t know how to make a diagnosis in other cultures, we were completely ignorant,” he said.
Following the devastation of more than 25 percent of the country’s population from 1975 to 1978 under the genocidal Khmer Rouge regime, Cambodians for example were thought of as having been stretched like a rubber band, he said. And as soon as peace came, the rubber band was thought to have snapped right back into place.
This thinking is still present in some cultures, and can be detrimental to recovery, according to Dyan Mazurana, research director at the Feinstein International Center, who said she isn’t very popular when she walks into donor and government offices.
“They say ‘you’re here again to talk about the war, we are so tired of thinking about and talking about the war.’ And I say: ‘But you must understand what has happened to people because it is shaping the present and will shape the future. We are not these rubber bands,’” Mazurana explained.
Education and work for psychosocial well-being
The ability to receive a higher level of education and access to resources to start a business or find a better job are the cornerstones of rebuilding after trauma.
“How do you move the people out of their depression?” Mollica asked. “Is work a therapy? My hypothesis is that work is a potent therapeutic factor in terms of recovering.”
It’s natural to think that in a health sector — pediatrics, obstetrics, primary medical care — that the issues of livelihood are going to be expressed through the systemic and physical complaints of the body, he said, but “this is an ideal opportunity for World Bank to make an investment in bringing the primary health care sector into the livelihood area.”
Mazurana pointed to a panel survey in northern Uganda, where the population has suffered terrible loss of life and livelihoods through armed conflict and widespread insecurity. The study looked in 2013 at 1,877 households to find out how people are surviving and recovering from conflict and what role internal and external support played.
Those who had the greatest wealth, assets and food security had their own livestock, their own business or were employed by the government, she explained, while those worse off were not more likely to receive livelihood services or social protection than the former.
If there is peace, people can find work — and when they find work and have money, it helps them deal with the trauma of having going through war and being penniless. But post-trauma livelihood opportunities may be nonexistent or exploitative, and markets can be weak and underdeveloped. On top of that, some livelihood programs and social protection services often benefit mostly the wealthiest and food-secure households.
“We have to respond to this different reality,” De Berry said. “You have to offer different things to different people. What gets offered under livelihood programs? Microcredit, inputs like seeds and plows, a very unimaginative package…the assumption is that that everyone will respond to that equally. But people have different vulnerabilities.”
And the connections between psychosocial and economic needs can’t be missed, she pointed out.
For example, what Ugandans want is a life full of laughter, and a life full of laughter means sustaining relationships with family; if you have better relationship with family, you’ll have more ability to succeed at agriculture, and the cycle goes on, De Berry said.
The key barriers to progress after trauma are inconsistent advocacy, affected people not organizing into a powerful lobby, as well as social stigma, according to Mark van Ommeren, a an expert on mental health and psychosocial support in emergencies at the World Health Organization.
Social stigma is often the reason that even festering wounds become ‘invisible’: war wounded are regularly forced off public transportation and pushed to the outskirts of villages.
“We have to address this if we think we’re going to get those kinds of people into a livelihoods program,” Mazurana said.
Wessells pointed to girl mothers drafted into the armed forces in Sierra Leone, Liberia and northern Uganda as an example of a highly stigmatized population that has made strides due to a ‘participatory action research’ approach, where locally driven groups define the problem themselves and design and implement steps toward solving it.
“It’s the importance of self-help,” he explained.
For nine months to a year, a group of 20 girls in each site convened their own group discussions, and, with the help and advocacy of community advisors, began sharing stories, starting small businesses and reintegrating into their community.
Though there were shortcomings to the programs — such as not involving their husbands or boyfriends in the conversation — the women began to meet their own basic needs and either put themselves or their children through school.
The process is long and slow, Wessells said, but it’s the combination of economic and psychosocial aspects that has made it most promising — and only when the women get support in both arenas will they begin to reposition themselves.
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