The above discussions have highlighted some of the differences that exist between conceptualizations and theories of psychosocial work with war-affected populations. These differences are also expressed in practice and in the types of interventions that are implemented. A particular rhetoric has developed around psychosocial interventions which glosses over some of these differences: almost all interventions claim to be culturally sensitive and community-based. A closer examination of actual programmes reveals important differences, however, in implementation. Some of these differences centre on the following issues.
Different understandings of the 'psychosocial needs' of a population
Some organizations assume that any group affected by armed conflict will be in need of psychosocial assistance. Such an assumption may lead to situations where no or only very superficial needs assessments are conducted, as the organizations see the 'psychosocial need' as self-evident, requiring no exploration or justification.
Other organizations use needs assessments that are based on the trauma model, for instance questionnaires that assess to what and how many distressing events individuals were exposed, and what symptoms of trauma are found in individuals. The assumption here is that counting the number of distressing events and the number of trauma symptoms gives an accurate reflection of what the psychosocial problems and needs of a population are.
A major criticism of these approaches is that they are based on a deficit model of communities and individuals. They assume that the community is lacking something. In the first case, where no or only a superficial needs assessment is done, it is assumed that the organization already knows in advance what the needs of the communities are. In the second case, a specific understanding of the effects of armed conflict, the trauma model, is used as a filter or lens through which a community's needs are viewed. In both cases, the strengths and resources of the community are not assessed or taken into account. In addition, the people themselves are not asked how they understand the experiences and events, or how they have affected their lives - only specific questions are asked that may not relate to the important aspects of people's' experiences.
A further issue is the debate around assumptions of vulnerability. Summerfield (1999) points out that many organizations assume a priori that certain categories of especially vulnerable people exist, and these are frequently orphaned children, women who have been raped, and widows. He takes issue with this: the focus on particular events (such as rape) may exaggerate the differences between people or particular population groups (e.g., children), running the risk of disconnecting them from others in their community and from the wider context of their experiences and the meanings they give to them. Ager (1997) describes the tension that exists between developing programmes targeted at specific groups within a community, and programmes designed for the whole population. He suggests that vulnerable groups may well exist within populations but that initial phases of a programme should be directed first towards the general population, and that later phases should be aimed more specifically at groups that seem to be coping less well with the difficulties they face. Vulnerability should thus not be assumed, but should be established through thorough needs assessment.
- Ager 1997 http://www.developmentinpractice.org/abstracts/vol07/v7n4a07.htm
- Summerfield 1999 http://www.sciencedirect.com/science?_ob=MImg&_imagekey;=B6VBF-3WR495S-F-1&_cdi;=5925&_orig;=search&_coverDate;=05%2F31%2F1999&_qd;=1&_sk;=999519989&wchp;=dGLbVtb-lSzBk&_acct;=C000010360&_version;=1&_userid;=126524&md5;=2d8665f861909103249f2bac6f7c6d59&ie;=f.pdf
Different understandings of 'culturally sensitive' or 'culturally relevant'
While the vast majority of psychosocial interventions claim to be culturally sensitive, vast differences exist between how they are implemented. Some programmes conduct group or individual therapy sessions with refugees, and because these sessions open with a prayer or a song they are presented as being culturally appropriate. Other programmes seek to find appropriate or similar words for trauma and stress in local languages, and believe that therefore they too are being culturally sensitive. Such programmes sees culture as an addendum to 'what is really going on', i.e. traumatization. They are based on a Western psychological approach to understanding distress, and view culture and context as 'external variables' that affect the particular local expressions of distress but do not change its basic form. The interventions based on such an approach frequently 'extract' a few cultural practices and attempt to incorporate these into existing programmes, for example through the incorporation of purification rituals into programmatic interventions or the promotion of 'cultural' activities like dancing and singing. The 'cultural' elements are seen as supplementing psychological methods (counselling, psychoeducation, etc.), but not as principal resources for dealing with distress. Such an approach does not do justice to local ways of understanding and expressing distress, nor does it recognize that context and culture permeate every aspect of suffering and the range of treatment options available.
This contrasts with programmes that perceive their role primarily as accompanying communities in the ways in which the communities have chosen to deal with the difficulties they face: rather than imposing outside solutions these programmes try to assist by facilitating local strategies through a variety of ways.
While most programmes lie somewhere in between these two approaches, it is important to be aware and critical of the current rhetoric around cultural issues in psychosocial programmes. The main issue is to what extent organizations see cultural and local understandings as central to their interventions (Wessells 1999) . Practitioners argue that only when local culture is taken as a starting point for needs assessments, planning, and implementation, and monitoring and evaluation can programmes be said to be culturally sensitive.
Different understandings of 'community-based'
Again, there are vast differences between programmes in this respect. Some programmes assert that they are community-based programmes because the activities take place within the geographical area of the 'community', for instance in a refugee camp or in a suburb of a town. These programmes may bring in psychosocial counsellors who do their counselling sessions within the camps, and this is seen as sufficient to label the intervention as a community programme.
Being community-based is not about the physical location of programmatic activities, however. It refers to the extent to which the community itself is involved in decision making with regard to the programme and in implementing the activities, and the degree of control the community has over the programme as a whole. Issues of conflict may arise where organizations have developed models for psychosocial interventions in their headquarters in the north, and seek to implement these in communities regardless of the specific local cultural and political contexts. Such organizations may expect community members to participate in these projects through volunteering (or payment) and may find that there is a lack of interest and a low up-take of services. Many times these failures are explained away on the basis of organizational factors, when in fact an examination of the fundamental approach to working with communities is needed.
The word 'community' is itself controversial, as it implies some kind of imaginary or physical boundary that separates a specific group of people from others. In post-emergency situations it may be difficult to determine what is or is not a community, for example amongst self-settled refugees who live alongside members of the host society in urban cities. Some humanitarian workers prefer to use the word 'population' to refer to groups of displaced people.
The central issue here is to distinguish rhetoric from implementation: to what extent are the displaced themselves involved in decision making, and the planning, implementation and evaluation of programmes intended for them? Community participation is central to effective psychosocial programming and Segerstrom (2001) provides some guidelines for achieving this.
- Segerstrom 2001 http://earlybird.qeh.ox.ac.uk/rfgexp/rsp_tre/student/commpart/toc.htm
Tensions between the local population and outside experts
Ager (1997) identifies the tension between the value placed on indigenous knowledge and the technical knowledge of outside experts as central to current debates in the field. Most agencies describe their programmes as an integrated approach that draws on the knowledge of both local and outside psychosocial 'experts'. Dawes and Cairns (1998) point out, however, that asymmetrical power relations between local and foreign systems and actors will continue to affect psychosocial interventions even when these seek to incorporate local approaches. A concerted effort is needed to prevent these unequal power relations, which may often be related to access to resources, from relegating local actors to a status of lesser importance in planning and decision making.
- Ager 1997 http://www.developmentinpractice.org/abstracts/vol07/v7n4a07.htm
Some example of types of programmatic activities
A few examples of common programmatic activities are briefly described here.
Primary mental health care approach
This approach is based on the notion that all psychosocial programmes should form part of existing health care systems, and that they should be incorporated into general health care delivery (Boothby 1996b) . Many developing countries who are affected by armed conflict have limited resources allocated to mental health care systems, and health care staff may not be trained or equipped to deal with mental health problems (World Mental Health Report 2001) . A primary mental health care approach is usually implemented through one of two routes: either through the training for health care personnel at institutional level, for instance in nursing colleges, or through the training of community health workers in psychosocial issues. The rationale for such an approach is:
that mental health should form part of general health care, as mental and physical well-being cannot be separated form one another
that mental health care is the right of all people living within a country, and efforts should thus be directed at the overall lack of provision in this area and not just at refugees or internally displaced people
that access to and delivery of these services is most effective when they are part of basic health care and not confined to specialized psychiatric institutions that require trained doctors and expensive drugs.
This approach is often implemented in displaced populations through networks of community health workers who are already involved in providing health education about common illnesses to the population. In Angola, for example, community health workers visit households, refer people to the clinic, and hold small meetings about issues such as diarrhoea, feeding practices, and water purification. As they themselves are part of the community, they know the households in their areas well enough to discern who is not coping with their experiences and who may be facing particular difficulties. When such community workers are provided with information about primary mental health care, they may initiate appropriate action which can range from starting mutual help groups to referrals to indigenous or biomedical services.
- World Health Report 2001 – Mental Health: New Understanding, New Hope http://www.who.int/whr/2001/en/
This approach involves training local people as counsellors who then work in the communities providing individual or group counselling to those identified as being in need of support. The training approaches and the types of counselling technique vary greatly, but most are based on the assumption that it is helpful for someone who has been identified as being distressed to verbalize his or her memories of events, and the emotions and thoughts the memories provoke (Van der Veer 1998) .
In some programmes the counsellors are not from the displaced community itself, but may be from the host community or may be living outside the area in which they are working. This may lead to friction and misunderstandings between counsellors and the displaced populations, as differences in educational background, language, culture, and political orientation may be pertinent.
Psychoeducation has been described by Van der Veer (1998) as a technique that involves explaining the cause of symptoms, and placing the person's experiences within a conceptual framework, which can lead to a reduction in feelings of helplessness and powerlessness. One of the main aims of psychoeducation is to assure people that they are experiencing emotions, thoughts, and behaviours that can be expected under conditions of war. This has the effect of 'normalizing' reactions to distress. The emphases placed on specific aspects of psychoeducation and ways of implementation vary, depending on what each programme regards as important to convey. Some programmes are public information projects that aim to provide information to the public about mental health issues, based on the assumption that such knowledge leads to insight, earlier detection of severe psychological problems, and possible prevention amongst the population. Most programmes place emphasis on informing people about reactions to distress and violence amongst adults and children, often with the aim of reassuring people that their reactions are normal. Psychoeducation may include guidelines on how to distinguish between normal and pathological reactions, or information about developmental psychology that will give parents and caregivers insight into the normal and abnormal developmental processes their children undergo.
The assumptions that guide the decision to use psychoeducation as an intervention strategy relate to the importance attached to particular information, its potential recipients, and the manner in which the information is conveyed. For instance, seminar-type situations may be used to train participants, as opposed to public gatherings, or the design of pamphlets, posters and the use of theatre to convey the information may be considered relevant. The term 'psychoeducation' is thus used to encompass a range of activities intended to communicate psychological knowledge, the content of which has frequently been decided upon a priori by service providers. Bracken et al. (1995) warn against an approach that aims to educate populations about the 'real' effects of violence, i.e. symptoms of trauma, as this may undermine local expressions and ways of dealing with distress. The manner and intention with which psychoeducational messages are delivered thus seem to be important.
In conclusion, some scholars continue to argue that the trauma model is the most appropriate way of conceptualizing the effects of war and of providing psychological assistance (Danieli et al. 1996) , while others call for a complete disengagement of the international aid community from this area of work (Summerfield 1996) . The most commonly expressed position, however, is that psychosocial work needs to engage critically with the concept of culture and with local contexts in order to avoid inappropriate and ineffective programme implementation (Wessells 1999) .
Agencies implement psychosocial programmes in war-affected areas around the world. There is thus a need to advance knowledge in this field, specifically in relation to the conceptualizations of distress, suffering, and trauma, and how these guide implementation practices.
- Bracken et al. 1995 http://www.sciencedirect.com/science?_ob=MImg&_imagekey=B6VBF-3YS8BF9-6-2&_cdi=5925&_user=126524&_orig=browse&_coverDate=04%2F30%2F1995&_sk=999599991&view=c&wchp=dGLbVlb-zSkzk&md5=6cd1a8cb6fd6be9905db0c0d2ada0b45&ie=/sdarticle.pdf
Monitoring and evaluation
The monitoring and evaluation of psychosocial interventions has been notoriously inadequate, with many project reports asserting the beneficial effects of their programmes purely through reference to a few anecdotal reports from beneficiaries. The need to develop more systematic and effective approaches to monitoring and evaluation has recently received attention, and several initiatives are under way to produce guidelines and manuals to help agencies undertake this task (e.g., MandENews, a website on monitoring and evaluation).
At present, few resources aimed specifically at evaluating psychosocial programmes are available, and practitioners have usually drawn on more general evaluation toolkits such as the one developed by Save the Children (1995) for assessment, monitoring, review, and evaluation of their programmes, or that for the evaluation of community programmes written by Feuerstein (1986) . Major differences in approaches to evaluation are evident and centre around the following themes:
outsider versus insider evaluations: is it always necessary or indeed desirable to bring in outside 'experts' to evaluate projects, or can project staff conduct their own evaluations?
methods: what are the most appropriate methods to answer questions of output, effects, and impact? What constitutes reliable data?
tools: what tools are the most appropriate for implementing the different methodological approaches to evaluation?
involvement of beneficiaries and participants in the project: to what extent are monitoring and evaluation participatory processes that involve community members themselves? How are results of evaluations reported to the communities?
monitoring and action research: to what use are monitoring and evaluation results put? Do they feed back into the project cycle or do they end up on office shelves?
- MandE NEWS http://www.mande.co.uk/
- Key readings on interventions
- Ager, A., 'Tensions in the Psychosocial Discourse: Implications for the Planning of Interventions with War-affected Populations'. Development in Practice, vol. 7, no. 4, 1997. http://www.developmentinpractice.org/abstracts/vol07/v7n4a07.htm
- Boothby, N., 'Mobilising Communities to Meet the Psychosocial Needs of Children in War and Refugee Crises'. In R. Apfel and B. Simon (eds), Minefields in their Hearts: the Mental Health of Children in War and Communal Violence. New Haven: Yale University Press, 1996b.
- Dawes, A. and Cairns, E., 'The Machel Report: Dilemmas of Cultural Sensitivity and Universal Rights of Children'. Peace and Conflict: Journal of Peace Psychology, vol. 4, no. 4, 1998.
- Save The Children Alliance, Promoting Psychosocial Well-being among Children Affected by Armed Conflict and Displacement: Principles and Approaches. International Save the Children Alliance, 14, 1996.
- Wessells, M., 'Culture, Power and Community: Intercultural Approaches to Psychosocial Assistance and Healing'. In K. Nader, N. Dubrow, and B. Stamm (eds), Honoring Differences. Cultural Issues in the Treatment of Trauma and Loss. Philadelphia: Bruner/Mazel, 1999.