it takes a village: community-based psychological recovery in complex emergencies

8/9/2019 It Takes a Village: Community-Based Psychological Recovery in Complex Emergencies

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IT TAKES A VILLAGE 1

It Takes a Village: Psychological Recovery in Complex Emergencies

Elena Cherepanov

Cite this paper:Elena Cherepanov, It Takes a Village: Psychological Recovery in Complex

Emergencies, International Journal of Psychology and Behavioral Sciences, Vol. 5 No. ,

!"5, pp. #$!5. %oi: ".5&!'().i)p*s.!"5"5"."'.

Boston MA


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Abstract

While qualitative and anecdotal field evidence provides poignant illustrations of the value of

Mental Health (MH) relief work, the professional community has yet to arrive at a conceptual

framework and evidencedbased practices! Additionally, the controversies surrounding

understanding MH needs in comple" emergencies, scarce resources and limited engagement time

of relief organi#ations, offset the recognition of accomplishments! $ne solution to this could be

a %ommunity&ased 'sychological ecovery (%&') paradigm where MH specialists partner

with the community to create selfsustaining support systems! t based on the recoveryorientedparadigm, where the success of individual psychological recovery determined by quality of

community support providing secure sense of self, supportive relationships, empowerment,

social inclusion, and meaning (*AM*HA, +-)! .rauma, violence and subsequent

marginali#ation challenges these supports! %&' aims to prevent posttrauma communal

violence and radicali#ation! t facilitates recovery by mobili#ing and strengthening recovery

resources, and sensiti#ing community to the needs of vulnerable groups! %&' model based on

the premise that! With training and support, the local trauma specialists in the disasters/, war and

ethnic conflicts #ones can become powerful agents of change in restoring and strengthening the

community/s capacity for selfreliance and healing! %&' models piloted in %hechnya,

%hernobyl, 0osovo, 1iberia, and 2! 3kraine!

0ey Words4 comple" emergency5 posttrauma violence5 disaster behavioral health, community

trauma, psychological recovery, sustainability, community recovery potential, functional

community

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A Brief History of the Mental Health Disaster Relief Work

n recent years, comple" emergencies, such as disasters, famines or armed conflicts have

increasingly become the priority of international disaster response and the relief work! However,

the 67$s (6on7overnmental $rgani#ations) have been incorporating mental health (MH)

elements into relief work in comple" emergencies since the early 89:/s, when the professional

relief community embraced the importance of attending to both physical and MH needs!

.remendous organi#ational development followed!n 899:, Medcinessans ;rontiers (M*;)

formally recogni#ed the need to implement mental health and psychosocial interventions as part

of the emergency work, though they had been using mental health professionals much earlier!

Already by +8+, M*; staff held 898,ong, the

M*; mental health advisor questioned, ?What do you do if there is enough food, but no one

wants to eat@? *ometimes people are unable to eat because they no longer want to live! .hey

may have witnessed the killing of their family,? adds =e >ong (+B) describing the MH needs

during &osnian refugee crisis!

.he late 89:/sCearly 899/s was a pivotal time in the field of trauma psychology! .he

inclusion of the '.*= diagnosis in =*MD was a maEor and inspiring victory for victims and

their advocates! .rauma psychology rapidly made maEor advances, mostly in '.*=

epidemiology! .he fascination with collecting and cataloging '.*= symptoms in various

populations soon raised questions about the validity of the syndrome in widely different cultures!

nternational relief work brought to the table firsthand e"perience of dealing with trauma in

diverse cultures! .heir work also raised specific concerns about the applicability of standard

'.*= assessment and treatment tools in different cultural and social conte"ts, the reduction of

normal human responses, and the comple" reality of trauma as related to the established set of

pathological '.*= symptoms! Fehuda and Mc;arlane (+9), in their passionate response to

growing critique of cultural validity of the '.*= diagnosis, argued that because '.*= has

become the whipping post for the challenges that emerging knowledge brings to the

classification of mental disorders suggests that the '.*= diagnosis has a strong cultural

resonance! .o strengthen their appeal, Fehuda and Mc;arlane begin their article with the plea not

to throw the baby out with the bathwater and concludes with the appeal not to shoot the

messenger! Along similar lines,Hinton G 1ewis;ernande# (+88) cautiously acknowledged the

legitimacy of concerns that even though there is some evidence of the crosscultural validity of
http://www.doctorswithoutborders.org/country-region/iraqhttp://www.doctorswithoutborders.org/country-region/iraq


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'.*=, the evidence of crosscultural variability in certain areas suggests the need for further

research! .hese authors recommend criteria modification and te"tual clarifications to improve its

crosscultural applicability! .his debate is a reflection of emerging and ongoing controversies

surrounding use of '.*= criterion in the crosscultural work!

While deploying MH modules in comple" emergencies clearly showed qualitative and

anecdotal benefits, despite growing multicultural questions, enthusiastic research was soon

confronted by the boring but unavoidable questions about standards of care, empirical research,

measurable outcomes and quality control!

An e"ample of the current state of affairs is the array of competing views on the outcome

indicators! .he opinions range advocating for the use of formali#ed but highly controversial 7A;

(7lobal Assessment of ;unctioning), as suggested by Dan $mmeren, G Wietse (+88), and, on

the other e"treme, to statements that standardi#ed evidencedbased practices are inapplicable in

comple" emergencies by definition! .hese apologists argue that every situation is unique, and

that there is no general tool to measure individual suffering, and any assistance makes victims

feel supported and thus has humanitarian value! $ther widely used efficacy criteria based on self

reported satisfaction, symptom reduction, or simply the number of sessions provided and persons

served! .he limited progress and lack of consistency in demonstrating the programs/

effectiveness to the professional communities, organi#ations, and donors continued to force the

question of the overall impact and value of this work!

.he second wind for MH in comple" emergencies research came in + when the 36

declared mental health a priority, but the real political push for global MH came later, in +8,

with the World Health $rgani#ation (WH$) eport on Mental Health, which highlighted the fact

that mental health has been neglected for far too long and is crucial to the overall wellbeing of

individuals, societies, and countries! .he report advocated for global policies changes that are

urgently needed to ensure that stigma and discrimination are broken down, and that effective

prevention and treatment are put into place!

n +


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stresses of life, can work productively and fruitfully, and is able to make a contribution to her or

his community . Mh7ap further outlined strategies aimed at improving the mental health of

diverse populations! *ince then, WH$ has undertaken different proEects and activities, such as

the 7lobal %ampaign Against 2pilepsy, the 7lobal %ampaign for *uicide 'revention, national

policy building on alcohol use, and assisting countries in developing substance abuse services!

n addition, WH$ proposed the guidelines for MH interventions in emergencies and a set

of activities that include support to countries in monitoring their mental health systems,

formulating policies, improving legislation and reorgani#ing the services! .he essence of

mh7A' is building partnerships for collective action and reinforcing the commitment of

governments, international organi#ations, and other stakeholders! WH$ guidelines also offered a

definition of comple" emergencies and outlined the general framework for MH policydevelopment in situations where comple" emergencies presented unique challenges due to their

systemic impact! As a result, in *eptember of +88, the 36 7eneral Assembly adopted the

political declaration on the international agenda on MH in the conte"t of disease prevention and

control! .here MH issues were recogni#ed as an important cause of morbidity and a contributor

to the global burden of noncommunicable diseases! .he 7uidefor ;ield Workers, developedby

War .rauma ;oundation in +88, operationali#ed the mh7ap guidelines for the mental health

workand recommended psychological first aid (';A) as intervention of choice in comple"

emergency overpsychological debriefing! While hardly anyone argues that ';A is universal and

useful set of skills to assist all the people in the immediate aftermath of disaster or acute crisis,

this claim seems questionable4 the debriefing has a different scope of applicability and is most

effective to aid relief workers after the e"posure to critical incident! .hese two methods are not

validly comparable, and the claim that ';A is an evidencebased practice has yet to be

substantiated which led to the change of terminology to informedbased practice definition of

what it is seems quite vague!

Is the Disaster Mental Health Module in Crisis?

.he semichaotic diversification of MH programmatic models, along with paucity of

evidencedbased practices, put pressure on MH to demonstrate its usefulness in comple"

emergencies! .o the layman, the element of mystery often surrounding the MH domain and


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psychological work in general often deferred inquiries about the programmatic choices with

regard to particular models and interventions! .his created a parado"ical situation when, while

the relief organi#ations embraced the importance of MH work and are mostly willing to move

forward the programs, the added value largely remains unclear! .his lack of clarity cast doubts

on the general ability of MH programs to fulfill their mission (What is this mission anyway@)!

After a fullthrottle start, the MH disaster relief module suddenly found itself in the middle

of heated debates about its strategic goals, its role in multidisciplinary relief efforts, and about

the most effective MH models and approaches! n the absence of conceptual clarity, the MH field

programs do not always include longterm strategic planning or considerations for sustainability!

.he programmatic decisions often made on an emergency basis and rather depend on the

organi#ational culture, and available resources (logistics, finances, and cadres) thenunderstanding of needs and value of the work! 2ven the needs assessment, the beginning of all

beginnings, remains highly arbitrary and depends on the organi#ational ideology! .he

methodology of the needs assessment greatly depends on the adopted theoretical framework and

school of thoughts4 every approach has a different understanding of problematic areas,

interventions and indicators of effectiveness! A psychoanalyst/s view of the needs, ideas about

effective interventions and treatment will differ from a cognitivebehavioral therapist or a crisis

counselor! As per this writer/s observation, the representation of multiple approaches in the field

may result in conflicting interventions and contradictory recommendations to the survivors,

bringing even more confusion into an already chaotic situation! While trial and error has its place

in relief workbased e"perimentation and assessment, it is vital that MH specialists receive some

kind ofpriorstandardi#ed training, adopt universal counseling skills such as motivational

interviewing, and use the evidencebased practices! A comple" emergency is not the right place

to e"periment with fad interventions or to settle theoretical differences! n the environment of

theoretical eclecticism and assessment fiefdoms, the organi#ations with field e"perience have

definite advantages in developing empirically sound MH programs!


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%urrent MH programs that are part of international disaster response can be grouped

dependently on the response phase (prevention, immediate response, longterm and chronic

issues) and the target need4

'rograms that provide immediate disaster response, trauma treatment in the aftermath or

war, famines and during disease outbreaks4 M*; (0osovo, &osnia, *ierra 1eone and

other), *$* Armenia (Armenia)5 .he Haitian Mental Health (HMH) 6etwork5

'rograms that gear toward behavioral health aspects of chronic disease or health

conditions management, HD, .&, epilepsy,psychosomatic complaints, ambiguous

medical diagnoses, comple" needs, stress and depression e"acerbating the health issues

and compromising the access to care!

Maternal and reproductive health, mother and child care and integrated primary care4

M*; (ussia, .aEikistan, *udan)5 .he 1ast Mile (1iberia)5 M=M (1iberia, *yria)

'rograms for victims of violence and genderbased violence4 M*; (=%, 'apua 6ew

7uinea and others)!

'rograms for special groups4 persons with mental health disabilities, children, adults,

orphans and other4 M=M (1iberia), *$* %hildrenIs Dillages nternational,*even Hills

nternational!

'articipation in community development, prevention, education, policies development

training the cadres4 %arter %enter (1iberia), M=M (1ongterm development program in

the 'hilippines), 'artners in Health (Haiti)!

Mollica et al! (+-, pp! +B:+JK) noted that mental health is becoming a central issue

for public health comple" emergencies and underscored the need for standardi#ed approaches to

the assessment, monitoring the outcomes of which is crucial to evidencedriven quality

improvement, and the dissemination of the results achieved! A thorough desk review of e"isting

psychosocial assessments and evaluations done by the Mailman *chool of 'ublic Health (+9,

p!


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1ack of clear and appropriate proEect obEectives5

A number of common methodological weaknesses in evaluations5

1ack of appropriate and standardi#ed quantitative tools for assessing psychosocial

wellbeing! .he strengths and weaknesses of the available tools lays in the culturalvalidity of underlying concepts and disagreements about what can be considered a

good outcome!

n the past years, there has been significant interest in developing the assessment tools

focusing on target issues such as depression, trauma or an"iety! Among them are Hopkins

*ymptom %hecklist+B (H*%1+B) ('arloff, 0elman and ;rank, 89B-) and the Harvard .rauma

Luestionnaire(Mollica et al!, 899)! .he methodologically novel and probably most promising

tools these days come from the medical primary care setting! .hese are the World Health

$rgani#ation Luality of 1ife (WH$L$1) (.he WH$L$1 7roup, 899:) and the Wellbeing

%heck (WH$B, 899:) (&ech, +8+)! .hese assessment tools developed a way of measuring

individual wellbeing in primary health care settings with both clinical and psychometric

validity, and they have larger applicability in comple" crisis situations where is difficult to single

out one factor determining the systemic impact! .hese portable instruments validated on many

languages and use positively phrased questions to avoid symptomrelated pathologi#ing

language!

Against the Odds: Progress and Ao!"lish!ents

n spite of all the surrounding controversy, the MH component in disaster relief work

remains an undisputed priority in the strategic development of the relief agenda! .he MH module

is steadily gaining recognition and acceptance, and the number of MH programs has been

increasing e"ponentially! =onors now e"press interest in prioriti#ing this area, and more relief

organi#ations routinely incorporate an MH module into their work! .he MH programs that

started as assistance to the survivors of natural disasters, wars, and refugees, are quickly

e"panding into supporting HD and .& patients, victims of crimes, torture, and genderbased

violence! .he relevance of MH relief programs continues to e"pand into other areas of acute and

chronic needs! nterest from the international professional community is reflected in the growing

number of publications on this topic and speciali#ed training for the relief of mental health


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workers! n the past, the autonomous data gathering, which was not always publically shared,

and unilateral programmatic decisions has been a longstanding tradition for 67$s! 6owadays,

there is a growing understanding of the importance of coordination of field MH services,

something that has been long accepted in medical care as a must do!? ;or e"ample, this writer

observed the efficacy of an international collaboration in 1iberia in the summer of +88! n the

aftermath of the %te dIvoire refugee crisis, the field organi#ations, such as 36H%, M=M

(Medicine du Monde), M*; (Medicine sans ;rontiers), .H (.iyatien Health), Handicap

nternational and others, have been sharing data and working closely together to develop the

collaborative program to fill the gaps in access to MH services, to address the needs on multiple

levels, and to establish continuity of care!

.hroughout the years of implementing the MH module, organi#ations accumulated agreat deal of e"perience5 where the empirical findings present more value than the theoretical

constructs! 3nfortunately, opportunities for the international professional relief community to

share their knowhow on a regular basis are still scarce!

Mental Health #eeds in Co!"le$ %!ergenies

Wisner G Adams (++), defined a %omple" 2mergencyas situation of disrupted

livelihoods and threats to life produced by warfare, civil disturbance and large-scalemovements of people, in which any emergency response has to be conducted in a difficult

political and security environment(p! 9).&y that definition, comple" emergencies result in

population displacement, the disruption of societal and community infrastructure, and

infliction of individual and collective trauma! %herepanov (+88) also argues that a comple"

emergency also challenges the community/s core capacity to support, protect and care! t

destroys the social and psychological infrastructure and compounds e"isting inflicted

individual and collective trauma! .he comple" emergency like any other severe trauma

evokes sense of hopelessness and helplessness! t carries potential to demorali#e,

disempower the community, and overwhelm its capacity to support its members! .his

e"ponentially increases the members/ vulnerability and contributes to further victimi#ation,

marginali#ation of victims, and the perpetuation of violence!


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According to *ummerfield (8999), while most trauma reactions are not pathological and

are normally e"pected, the life of trauma survivor remains profoundly altered for years to come!

=e Foung and 0leber (+8), =e >ong, 0omproe G Dan $mmeren (+ones et al, (+9)

demonstrated that the severe traumati#ation (such as witnessing or being a victim of violence

especially genderbased violence, e"periencing sudden and violent loss of family members,)

consistently results in a multitude of chronic mental health issues! Among them, there are

profound mood and behavioral changes, severe sleep problems, an"iety, depression, flashbacks,

intrusive recollections, hypervigilance, and an increase in uncontrolled anger, along with the

psychosomatic complaints that overwhelm regular primary care! n +8-, %herepanov described

how the e"perience of traumati#ation sabotages helpseeking behavior, brings negative changes

in the family relationship and engenders hopelessness, helplessness, and selfneglect! .hese in

turn contribute to substance abuse, violence, suicidal behavior, nonadherence to essential

medical treatment, and, according to *chnurr, 7reen and &onnie (2ds) (+9), increases

mortality and morbidity! $n the other hand, effective coping with trauma can create personal

growth and enhance the ability to understand and support others, as .edeshi G %alhoun

described in their concept of 'osttraumatic 7rowth (+-)! According to %herepanov (+88) and

'earson, %herepanov (+8+), a mature functional community that collectively survived and

overcame traumatic event becomes more resilient, caring, and supportive to its members, and is

better equipped to cope with future adversities!

2"isting controversies in understanding collective trauma predominantly revolve around the

understanding the psychological needs! f trauma reactions in the conte"t of comple"

emergencies are e"pected and nonpathological responses to life adversities, this would indicate

that any e"ternal psychological intervention has potential of doing more harm by imposing

culture incongruent e"pectations and interfering with the natural course of psychological

recovery! Hans *talk, M*;Holland MH advisor, challenged even the use of the termMental

Healthdue to its inherently pathologi#ing connotation (2lena %herepanov, personalcommunication, +8)! At the same time, the currently employed termDisaster Behavioral

Healthhardly sounds less stigmati#ing due to the awkward assumption that there is such a thing

as healthy behavior in disaster! *ummerfield (8999) amplified these concerns suggesting that

any Western models of mental health problems, their assessment and treatment

recommendations, and the concepts of depression and '.*= in particularly, have no relevance,


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are intrusive and imposed on different cultures with little consideration to cultural

appropriateness, and thus create more harm interfering with the course of natural coping and

creating iatrogenies! *ummerfield (8999) went on arguing that the MH module is selfserving

and benefits nobody else but the MH workers themselves! .he quest to determine the MH needs

in comple" emergencies led =e >ong G 0ebler in +8 to introduce the psychosocial approach

which since then became the golden standard of the MH relief work! .his approach suggests that

the psychological needs in disaster cannot be separated from the social needs, and both social

and psychological supports are only effective when provided simultaneously! n +88, =e >ong

developed the guidelines for this approach that consistently demonstrated its effectiveness in

working with survivors of genderbased violence! .he cultural relativism suggested by

*ummerfield, was nicely balanced by =e >ong/s emphasis on the universal value of basic needs

such as need in food, shelter, safety and being free from the abuse and violence! n spite of the

seeming contradiction, these schools of thoughts actually complement each other, that there are

different individual, cultural or community needs that require different approaches! .hese two

e"perts in the global mental health issues, coming from very different frameworks, both found

themselves being very concerned over the patologi#ing the trauma reactions

.he most effective psychological approach in comple" emergencies is yet to be determined,

and the declaration of the superiority of some approaches over others goes beyond the scope of

this article! As *ou#a, Fasuda G %ristofani (+9) described the M*; proEect at Habilla, =arfur,

the integration of MH into theprimary care systemworked well and corresponded with the

advances in community health care, such as ntegrated %are and .raumanformed care

frameworks (pp!8:)! .he main benefits of ntegrated MH models are4

Many trauma survivors have concurrent medical conditions5

'rimary care providers identify and make referrals for those with ambiguous or additional

mental health needs5 psychosomatic complaints are often the initial reason to seek a

treatment5

MH services often carry a stigma! 'articipation in a standalone MH program may feel

unsafe and stigmati#ing for survivors and e"pose them Eust by virtue of seeking treatment5 on


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the other hand, receiving medical services is considered to be a much more socially

acceptable alternative5

.he integrated model identifies nonmedical sufferers and brings focus to those with more

severe impairment5

t assures the continuity of care, smooth and seamless handoffs between the programs5

=espite all of the great things about this model, it has its limitations! .o be sustainable, the

provided supports and treatment need to be backed up by concurrent multidisciplinary systemic

changes4 helping a victim of domestic violence is as effective as the availability of legal,

psychosocial and logistical (shelter, finances, employment) followup and support! Another

e"ample is the diagnosis of HD which is Eust the beginning of the Eourney, where the treatment

success depends on many interconnected factors where some are psychological (depression

affects the treatment adherence), while other are medical, but also the quality of social supports

and access to the medications and aftercare!

Co!!unity&Based Psyhologial Reo'ery

n +-, *ubstance Abuse and Mental Health *ervices Administration (*AMH*A in its 6ational

%onsensus *tatement on Mental Health ecoverydefinedmental health recovery as the process

of change through which individuals strive to improve their health and well-being, live a self-

directed life, and strive to achieve their full potential..he success of individual recovery is

mitigated, to a great e"tent, by the community which provides the social infrastructure, a secure

base and sense of self, supportiverelationships, empowerment,social inclusion, coping skills,

and meanings! .he latest advances in community mental health research and practice prioriti#e

the communitybased changes in support systems as one of the most important factors shaping

the recovery of the individual trauma survivor!*AMH*A introduced the traumainformed careparadigm, which emphasi#es the importance of focusing on strengths and resiliencies instead of

weaknesses and vulnerabilities in trauma survivors!.he 6ational %enter for .rauma nformed

%are (6%.%, n!d!)views traumainformed care and quality of supports as the hallmark of

effective programs to promote recovery and healing through support from peers, survivors, e"

patients, and recovering persons! 7oodman, et al, views the community as a powerful protective
http://en.wikipedia.org/wiki/Interpersonal_relationshiphttp://en.wikipedia.org/wiki/Interpersonal_relationshiphttp://en.wikipedia.org/wiki/Empowermenthttp://en.wikipedia.org/wiki/Social_inclusionhttp://en.wikipedia.org/wiki/Social_inclusionhttp://en.wikipedia.org/wiki/Value_(personal_and_cultural)http://en.wikipedia.org/wiki/Interpersonal_relationshiphttp://en.wikipedia.org/wiki/Empowermenthttp://en.wikipedia.org/wiki/Social_inclusionhttp://en.wikipedia.org/wiki/Value_(personal_and_cultural)


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factor that can mitigate social ills and outlines the aspects that are keyto this construct,

including4 participation and leadership skills, informational and logistic resources, socialand

inter-organi#ational networks, the sense of community, and an understanding of community

history, community power,community values, and critical reflection (899:, p! :-)!

.his author reasons that comple" emergency destabili#es or destroys the community/s

social and psychological support systems and shatters the routine of daily life! t overwhelms

community resilience, undermines coping capacities and heightens systemic vulnerabilities that

have significant implications for the psychological recovery! .he proposed %ommunity&ased

'sychological ecovery in %omple" 2mergencies model, or %&', prioriti#es the restoration of

community supports and sensiti#es the community to the special needs of vulnerable groups,

including persons with severe trauma or serious mental illness! t/s thought that mobili#ation ofthe communitys recovery potentialcan be achieved by concurrently addressing multiple layers of

communal functioning, ranging from the mobili#ation of pree"isting, culturebound traditional

supports, psychoeducation, to the restoration or development of new life routines along with

improving access to professional mental health!

.he author piloted the elements of this model in %hechnya, %hernobyl, Macedonia and

2astern 3kraine, and it was implemented as complete set of strategies in 1iberia in the summer

of +88 as part of .iyatien Health program (.he 1ast Mile)! .his proEect focused on developing

communitybased support groups to facilitate the community recovery in the aftermath of the

%te dIvoire refugee crisis! .his model demonstrated high efficacy in achieving the sustainable

positive changes on the community level! .he support groups continued at least three years later,

and the community members were coming together when felt the need for support, and only the

health crisis with 2bola interfered with community gathering and interaction! .his success has

been attributed to the choice of the target format, the support groups, which was built upon

traditional 'alava practices (!alava is the organi#ed talk or discussion in the West Africa) when

people come together during challenging times to discuss the solutions!

Co!!unitys Reo'ery Potential


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.he contributing factors shaping community psychological recovery in the postdisaster

period are analy#ed through the lens of the communitys recovery potential, which is defined here

as set of psychological, social, and logistical resources, healing routines, and resilience! .his

includes past e"perience of survivorship, problemsolving protocols and decisionmaking scripts,

healing and helping traditions4 e!g!, culturallyspecific norms and e"pectations of helping

behavior, supporting those who e"perienced victimi#ation or loss, funeral rituals, attitudes of key

community players and role models! " functional or supportive communityhas systems in place

to maintain the order, protect its members, and prevent victimi#ation! Along with official law

enforcement, the council of elders, spiritual leaders, and traditional healers, neighborhood or

village forums often serve to solve collective problems and improve the wellbeing of a

community! Here are Eust some of the e"amples4 in Western Africa, the mediation facilitated by

'alavers, elders or wise people with special conflict resolution skills! n many cultures

(%hechnya, Armenia, 1iberia and other), there are systems in place to protect the victims of

domestic violence4 a battered woman can seek protection from older men in the community and

in the family! .he community marginali#ation, such as forced migration, destroys these supports!

Another e"ample of community safeguards is found in the remote villages of 2ast 1iberia! A host

family e"pected to introduce newcomers to the community at the village gathering and carries

full moral and often financial responsibility for the delinquent behavior of this newcomer! .he

functional community imposes and enforces behavioral and moral norms! n a village in 1iberia,

rape could result in e"pulsion from the village not only the rapist, but also the rapist/s family (2!

%herepanov, personal communication, +88)! When the physical survival depends on the

communal supports, this serves as harsh punishment for the whole family and as a strong

deterrent for others!

.he community marginali#ed because of comple" emergency, is no longer able to

provide the protection to its members, which increases the possibility for their victimi#ation! !

.he lack of safety may trigger a heightened sense of vulnerability and the negative group

dynamics that can perpetuate violence such as scapegoating, revanchism, or vigilantism! .his

alters the social and psychological fabric of communal life, brings polari#ation and create the

breeding ground for radicalism which can demorali#e an already wounded and traumati#ed

community! A comple" emergency, such as a mass forced migration, weakens sense of social


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inclusion and increases personal vulnerabilities, making members susceptible to both

victimi#ation and identification with the perpetrator! .o reclaim the communal safety when

unable to or culturally conditioned not to trust governmental law enforcement, the refugees in the

camps or the resettled communities at times build alternative selfdefense structures that

eventually claim more power! A subgroup could assume responsibility forpolicing,Eudging and

punishing! As this author observed in the refugee camps of %hechnya, 0osovoNMacedonia, and

1iberia, while selfrighteous vigilantism and scapegoati#m sometimes creates illusion of order, it

easily becomes problematic, brings in more violence and results in further victimi#ation!

Co!!unity&Based Psyhologial Reo'ery Model in Co!"le$ %!ergenies

#he model of $ommunity-Based !sychological %ecovery &$B!%' aims to achieve

sustainable community-level impact by strengthening community supports and by sensitizing the

community to special mental health needs of vulnerable groups. #he ultimate goal of the $B!%

model is to restore the communitys self-reliance and capacity to support its members!

%ffeti'eness Indiators: What is )untional Co!!unity

.he effectiveness indicators for this %&' model are yet to be standardi#ed, and themaEor challenge lies in the question of how we definefunctional or supportivecommunity!

'robably, this community is socially inclusive, capable of coping with adverse life events, and

being kind and supportive to its members, in addition to good conflict resolution capacities!

%ulturallybound and social supports, routines and traditions ensure smooth daily functioning for

the maEority5 even then, persons with disabilities often remain e"cluded from communal life due

to widespread stigma and preEudices! $ther parameters include the community/s self

determination and selfreliance, functioning systems of communal support, conflict resolution

and victim support protocol! .he functional community discourages violence and enforces social

norms5 it offers supports for the routine life challenges such as illness, death, violence, and the

loss of property! .here is a respect of different cultures and subgroups4 in 6orth %aucasus, before

the first %hechen war, there were over JB ethnic groups sharing the same small piece of land!

According to a teacher from a small village in the region, the community identity carried more
http://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=1&cad=rja&uact=8&ved=0CCUQFjAA&url=http%3A%2F%2Fwww.thefreedictionary.com%2Fvoluntaristic&ei=9RQnU6nlE6L20gHS54DQBA&usg=AFQjCNGgMKy8d5tJNMni_enn5s5HWtKCKw&bvm=bv.62922401,d.dmQhttp://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=1&cad=rja&uact=8&ved=0CCUQFjAA&url=http%3A%2F%2Fwww.thefreedictionary.com%2Fvoluntaristic&ei=9RQnU6nlE6L20gHS54DQBA&usg=AFQjCNGgMKy8d5tJNMni_enn5s5HWtKCKw&bvm=bv.62922401,d.dmQ


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importance than even ethnic identity, or was at least equal to it! 7rowing up together in such a

multicultural environment, the children had many holy days C both, %hristmas and 6avru#

simply meant they would get treats (2! %herepanov, personal communication, May +8


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A community strives to achieve recovery, stabili#ation, and selfreliance5

2ach community even during the most difficult times possesses significant resources of

strength that come from4

o past survival e"perience

o community, social and cultural history, values and traditions

o concern on the part of key community players for the wellbeing of the

community

o traditions and customs of selfreliance, mutual support, resource sharing, and trust

*pecial needs groups, such as the disabled, elderly, children, those with severe trauma

reactions, or serious mental illnesses, may need additional supports5

Any humanitarian aid (logistics, services, food, or medications) is temporary and maydiscontinue at any time without much notice5

Any helping intervention carries the potential to impinge upon community selfreliance

by creating dependency on e"ternal resources5 2very community has both formal and

informal leaders who, in an emergency, will step up, take charge of recovery and inspire

and carry on values of kindness, compassion, sharing, caring and helping others5

When fleeing, refugees bring with them the psychological prototype of their community!

n a new place they try to replicate the routines, traditions, social and psychological

connections which include the collective survivorship e"perience and mutual supports,

but also myths and misconceptions about mental health issues5

An effective communitywide intervention is a strategically chosen small change in the

community system that may have a ripple impact and yield significant systemic results5

2very community has both formal and informal leaders who, in an emergency, will step

up, take charge of recovery and inspire and carry on values of kindness, compassion,

sharing, caring and helping others5

O"erational *uidelines

$perational guidance puts into practice the assumptions and concepts, outlines the scope of

services, defines and prioriti#es tasks and suggests the best practices and standards! n order to

achieve communitylevel systemic sustainable recoveryoriented changes, it is particularly


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important to have consistency in the approaches that aim at the restorationNrebuilding of the

community/s capacity to take care of itself by supporting its members! .his challenging task

accomplished by4

2"amine the community/s precrisis functioning5 past e"periences of survivorship and

resilience, historical and present cultural, traditional and unique sources of strength and

coping, the hopes and the vision for the future5

dentify key community players and leaders and map their social interactions and hierarchy5

=evelopment of active collaboration with local establishments and organi#ations , such as

public health or traditional healing practices5

Active engagement of specialists, local cadres and the community leaders and building upon

the intact infrastructure, available support systems, traditional routines5

dentify vulnerable groups and evaluate the available supports and community attitudes

toward them5

;ind out about the communityrooted activities, including recreational activities, effective for

strengthening community identity and cohesion! n many communities sports serve this

function5

2mpowering, encouraging and fostering compassion, mutual support and destigmati#ation5

*trengthening of the community/s role in recovery by promoting its ownership, leadership

and responsibility for the wellbeing of its members5 2ngaging the community members, the

formal and informal leaders in the recovery process5

%oncurrent multilayer and multifaceted education and skill building in providers, leaders

and community members to achieve consistency across the community systems! 2ducation of

the community and providers (teachers, health care providers, spiritual leaders and traditional

healers), challenging the misconceptions, such as myths about perceived dangerousness and

dehumani#ation of people with mental illnesses, contagiousness of epilepsy, blaming peopleor their families for mental health problems5

When possible and beneficial, collaborating with established care systems including

government and public health organi#ations, spiritual leaders, and traditional healers5


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ncrease in mental health competencies in the community by training of local cadres and

health providers in compassionate care5

2stablishing the systems of intermediate care for those with greater mental health needs, such

as individual counseling, integrated primary health care, special programs, aftercare and

community outreach5

*treamlining the referral system, availability and access to traumainformed psychiatric care,

medications and counseling for persons with severe mental health issues, ndependently on

the feasibility of psychiatric services, education on the nature and causes of mental illness,

trained on how to support persons with serious mental illness and their overwhelmed

families, including how to manage risks!

;ollow up! While there is an e"pectation of independent sustainably in the functioning of

support groups, the ongoing support, supervision and retrainings for the peer volunteers or

champions of change is very important!

3nassumingly and realistic evaluation of e"isting practices from the harmreduction point of

view4 some traditional healing practices for mentally ill look very much like torture! $n the

other hand, the widely condemned as abusive by professional community practices of

chaining the mentally ill, in the absence of antipsychotic medications, in some instances are

used for the protection of persons with psychotic disorders have been kept physically

restrained to prevent them from wondering away and being raped or even killed (2lena

%herepanov! 'ersonal communication, +8+)5

Any planning for relief program must include an e"it strategy and plan for ensuring the

sustainability of the recovery process and reduction in dependence and reliance on e"ternal

resources!

Conlusion

.he sustainability of communitybased psychological recovery can be assured by

strengthening the role of the community itself! .he communitybased psychological recovery

(%&') approach views the individual trauma recovery process as a part of sustainable changes


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within a community/s support systems that enhance the community/s capacity to cope with

current and future challenges! 2"clusive focus on the individual trauma survivors without

concurrent systemic and substantial changes in the community is ineffective and carries high

potential for retraumati#ation as the victims continue to be dehumani#ed and stigmati#ed! .he

capacity building and the sustainability of the communitybased psychological supports achieved

by actively engaging the community members in recovery efforts, by educating and sensiti#ing

them to the needs of vulnerable groups! .he community cannot be forced to recovery! n %&'

model, MH work plays active role in facilitating, assisting, strengthening and enhancing the

natural recovery process by offering education, engagement, and empowerment, building upon

the community capacity for mutual supports, and encouraging the leadership in the recovery! t

is crucial that strategic planning for disaster MH program from the very beginning build upon the

community strength and resources, and involves steps to reduce dependence and reliance on

e"ternal aid!

Referenes

&ech '! Measuring the dimensions of psychological general wellbeing by the WH$B! Lo1

6ewsletter +-5 ! (+8)! &uilding %ommunity %apacity4 a =efinitional ;ramework and %ase

*tudies from a %omprehensive %ommunity nitiative!(rban "ffairs %eview )**+/)0+-

).

%herepanov, 2!, yan, M! (899J) .raining of Au"iliary Mental Health Workers! n4 #he

1rontline $ounselor.$fficial 'ublications of the nternational Association of .rauma

%ounseling, p!ones, 1!, Asare, >!, Masri , 2l M!, MohanraE, A!, *herief, H!, Dan $mmeren M! (+9)! *evere

mental disorders in comple" emergencies!


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.he WH$L$1 7roup (899:)! .he World Health $rgani#ation Luality of 1ife assessment

(WH$L$1)4 =evelopment and general psychometric properties! *oc *ci

Med!5-J48BJ9C8B:B!

*AMH*A (n!d!)!2ational $onsensus 4tatement on Mental Health %ecovery,3*A! etrieved

fromhttp4NNwww!samhsa!govNrecovery

*chnurr, 'aula '! (2d)5 7reen, &onnie 1! (2d) (+-)! .rauma and health4 'hysical healthconsequences of e"posure to e"treme stress! Washington, =%, 3*4 American 'sychological

Association! "ii


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Wisner, &!, Adams, >! (2ds!) (++)! :nvironmental health in emergencies and disasters/ a

practical guide! WH$, 7eneva! etrieved from4

(http4NNwww!who!intNwaterOsanitationOhealthNhygieneNemergenciesNem++intro!pdf

Dan $mmeren, M!, .ol, G Wietse ! (=raft Dersion)! (;ebruary +88)!"ssessing Mental Healthand !sychosocial 2eeds and %esources/ #oolkit for Ma?or Humanitarian $rises! WH$4

7eneva! (http4NNmhpss!netNwpcontentNuploadsNgroupdocumentsNJKN8

it takes a village: community-based psychological recovery in complex emergencies

Documents