COMMUNITY MENTAL HEALTH AND WELLBEING: A CASE STUDY

JANAKA JAYAWICKRAMA, PhD

SEPTEMBER 2010

Community-University Collaborations: Exploring

Models, Sharing Good Practice

Durham University

GENESIS

• UNHCR partnership to evaluate mental health and wellbeing interventions for refugees in Malawi.

• Additional accompanying field work was conducted with support from UNHCR.

PURPOSE

• To analyse the nature of individually and communally focussed mental health and wellbeing interventions for developing country communities that are affected by conflicts.

RATIONALE TO THE STUDY

• International Agencies including the UN have identified how wellbeing challenges lack appropriate policies and interventions implying that evaluations are required that include further investigations of the traditional knowledge systems of communities.

MOST INFLUENTIAL LITERATUREName SubjectDerek Summerfield – 1995, 1999, 2005

Critique of Mental Health in Humanitarian Assistance

Arthur Kleinman – 1988, 2005, 2006

Risk Reduction Vs Uncertainty/ Medical Anthropology/ Traditional Knowledge Systems

John Van Eenwyk – 2002

Traditional Knowledge Systems and Mental Healing of Torture

Amartya Sen – 1993, 1999

Development as Freedom

MOST INFLUENTIAL LITERATUREName SubjectLao Tzu – circa 100 BC

Tao Te Ching – Ancient Knowledge

Walpola Rahula – 2003

Compassion, Uncertainty and Danger

Religious Texts Different Perspectives on Life, Mental Health and Wellbeing

Folk Stories Different Traditional Knowledge Perspectives on Wellbeing

MAINSTREAM LITERATURE BODYClinical Psychology and

Trauma/ PTSDInternational Standards

and PracticeWellbeing and

Capability

• Uncertainty and dangers are abnormal in life situations.• Suffering is avoidable. • Human conditions can be controlled.• Interventions to address suffering should be objective.• The individual is the most important entity in social settings.• Life is predictable / manageable.

What are the strengths and weaknesses of individual mental health and wellbeing interventions and their appropriateness in

developing country, conflict affected communities?

(Source: Author)

Place

Purpose

Quantitative Assessment

Judgement and Analysis

Qualitative Analysis

UNHCR Malawi

Evaluation of Programme

Re-examine 163 Responses

Judgement of Practice: difficult to analyse information

16 Detailed Responses

Posi

tivis

tC

ritic

al

Rea

lism

Subj

ectiv

ism

? THE RESEARCH PROCESS

(Source: Author)

FROM PRACTICE TO POLICY

(Source: Author)

2. Qualitative: Key interviews

1. Quantitative: Evaluations

Policy

Programme

Practice

Evaluation Criteria (Adapted from OECD)1 Theoretical basis / Relevance2 Coverage3 Efficiency4 Effectiveness5 Impact6 Community7 Sustainability

Burden of delivery

Burden of policy

Different research steps

3. Literature review and secondary

readings on policies

MALAWI

• One of the poorest countries in Sub-Saharan Africa.

• Evaluation of mental health and wellbeing interventions of UNHCR partners.

• Mainly refugee communities from other African countries.

EVALUATIVE JUDGEMENTCriterion Aspect

Measured /Assessed

Source of Viewpoint

Methodology

Theoretical basis Developed by foreign consultants and staff in Geneva.

UNHCR Staff members and policy documents

Interviews and review of documents

Coverage Quantitative coverage of refugees. However, there are many gaps in qualitative coverage.

Refugee communities and field staff of UNHCR partners

Interviews and observations

EVALUATIVE JUDGEMENTCriterion Aspect

Measured /Assessed

Source of Viewpoint

Methodology

Efficiency Social, political, cultural and economic problems in project delivery.

Refugee communities and field staff of UNHCR partners

Interviews and observations

Effectiveness Objectives set by UNHCR are not agreed by partners or refugee communities.

UNHCR Staff, Refugee communities and field staff of UNHCR partners

Interviews and observations

EVALUATIVE JUDGEMENTCriterion Aspect

Measured /Assessed

Source of Viewpoint

Methodology

Impact No changes to refugee conditions in terms of policy or practice.

Government of Malawi, UNHCR Staff, Refugee communities and field staff of UNHCR partners

Interviews and observations

EVALUATIVE JUDGEMENTCriterion Aspect

Measured /Assessed

Source of Viewpoint

Methodology

Community No ownership or responsibility over activities.

Refugee communities

Interviews and observations

Sustainability Short term planning. No concepts of sustainability.

Government of Malawi, UNHCR Staff and field staff of UNHCR partners

Interviews , observations and review of documents

EMERGING THEMESPopulation Emerging Themes Malawi: Conflict affected refugee communities

Uncertainty and dangers are unavoidable

Suffering is part of being human

Not taking action to deal with suffering

Taking action to deal with suffering

Helplessness and powerlessness

Sadness and unhappiness

Needing help

Going back to old life styles Moving on and planning for

a future Worry about the future Importance of community

and family Value of religious support

(i.e. God) Experience of torture and

violence Community support Security and protection

DISCUSSION: COMMUNITY PERSPECTIVE

Community Different understanding of uncertainty and dangers to that of the academic and policy worlds

Tendency for activities of agencies to be largely irrelevant

Use of traditional knowledge systems: religions, folk stories and traditional healing/medicine

WELLBEING TIM

E

Uncertainties and Dangers

Community systems (Sensitive to outside

pressure) – maintain a low level from an outside view, but

sustainable wellbeing

Interventions (insensitive to community systems) – maintaining a total greater

wellbeing, but insensitivity leads to recurring uncertainties and dangers

Source: Author

Preconditions

Trust Conformity Genuine

engagement Transparency Accountability Equal participation Ownership and

responsibility

Knowledge retrieval through collaboration between insiders and outsiders

Retrieved knowledge systematised and validated

within its own cultural setting

Setting up of ecologically sound knowledge systems to

deal with suffering and improve wellbeing

Creative and flexible processes of implementing

knowledge systems

Sour

ce: A

utho

r

BIBLIOGRAPHYCollins, A.E. (2009) Disaster and Development, Routledge

Perspectives in Development Series, LondonCraig, D., Porter, D. (2003), “Poverty Reduction Strategy

Papers: A New Convergence” World Development, 31(1), 53–69

Das, V., Kleinman, A., Ramphele, M., Lock, M. and Reynolds, P. (eds) (2001), Remaking a World: Violence, Social Suffering and Recovery, Berkeley: University of California Press

Hancock, G., (1989), Lords of Poverty: the power, prestige, and corruption of the international aid business, The Atlantic Monthly Press, New York

BIBLOGRAPHYJayawickrama, J, (2007), Concepts of Care: A Workbook

for Community Practitioners, DDC and UNHCR, Geneva

Kleinman, A. Das, V. and Lock, M. (eds) (1997), Social Suffering, Berkeley: University of California Press

Kleinman, A, (2006), What really matters: Living a Moral Life Amidst Uncertainty and Danger, Oxford University Press

Sen A. (1993). Capability and Well-being, In Nussbaum and Sen (Eds.) The Quality of Life. Oxford: Clarendon Press

BIBLIOGRAPHY

Sen. A. (1999), Development as Freedom, New York: Random House

Smillie, I and Minear, L (2003), The quality of money: Donor behaviour in humanitarian financing, An independent study, Humanitarianism and War Project, The Feinstein International Famine Center, MA

Summerfield, D., (2005a), What exactly is emergency or disaster ‘mental health’?, Bulletin of the World Health Organization; 83(1), (pp.76-77)

UNHCR (2007) A Community –Based Approach to UNHCR Operations

JANAKA JAYAWICKRAMA, PhD

COMMUNITY WELLBEING PROGRAMMEDISASTER AND DEVELOPMENT CENTRESCHOOL OF THE BUILT AND NATURAL

ENVIRONMENTNORTHUMBRIA UNIVERSITY

j.jayawickrama@northumbria.ac.uk