Mass conflict and care in war affected areas. In search of assessment and psychosocial intervention

Abstract

Research in this thesis is focused on the relevance of psychosocial programs in areas of mass violence. Central questions are: how to assess needs in terms of psychosocial health, how to best address those needs, and what is the effectiveness of these mental health interventions? Our findings in Chechen, Ingushetian, Kashmir and Somalia population surveys show that at least one third (varying from 30%-80%) of the respondents suffers from substantial psychosocial complaints. The use of traumatic exposure, the level of witnessed, self-experienced traumatic events proofs to be problematic. The experience of violence does not differentiate sufficiently and the others fail to show a relationship with PTSD prevalence. Seemingly, people living in areas of mass violence perceive violent events as potentially traumatic only when the events are out of proportion to the context. We found alternative indicators such as: currently feeling safe, being forced to move, not being able to and cutting back on work to be associated with psychosocial vulnerability. Psychosocial surveys are often criticised for their methodological shortcomings which lead to overrated prevalence outcomes. Comparison of our with other survey results shows that most of our survey outcomes give a realistic indication of psychosocial needs. For future assessments we suggest to differentiate between emergency settings (use alternative markers that signal psychosocial vulnerability) and ‘stable’ violent settings (uselocally defined and cross-culturally, validated instruments). Currently, an overall consensus on goals, strategies, and methods of psychosocial support delivery in areas of mass violence exists. Our research gives substantial input on the making of these guidelines. Recruitment, training of national staff, their involvement program design is essential. But only an appropriate balance between their perspectives and the expert input ensures local acceptable, quality services. Our model evolved from the individual, trauma perspective as point of departure into an intervention that includes general community problems associated with living in violence. A step-wise approach is advocated. In acute emergencies psychosocial programs apply a ‘strict’ medical, vertical approach to ensure survival of the most vulnerable. In chronic crises more emphasis is given to people’s ability to cope with and adapt to their new situation. Our research and a literature review shows evidence for the effectiveness of psychosocial interventions. In our Bosnia study we find that 71% of the 5066 beneficiaries have significant symptom improvement. PTSD interventions must include exposure as a key ingredient. Also, various forms of lay counselling prove to enhance the client’s functioning. Symptom reduction and improvement of the individual’s ability to function are crucial for the survival of both the individual and the group. Major cross cultural limitations triggered us to look into alternative evaluation methods. We experiment with the scaling monitoring method using both client and beneficiary perspectives for evaluation. It showed good validity. Further research into the evaluation methods and the effectiveness of psychosocial interventions is needed. Top priority is to apply cross-culturally valid and locally developed psychological ill health concepts and instruments. Currently, in emergencies such as Syria, and the Central African Republic we know what to do; an existing effective psychosocial intervention model for these contexts exists.