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Overview

Overview

A web-based study of psychosocial resources and documents reveals that there is not a balanced representation of different positions and approaches to the issues on the Internet. While there is a large amount of literature on post-traumatic stress disorder (PTSD) on the web, very few documents and resources that present a cultural or community-based approach to psychosocial issues are available on the Internet. One of the reasons for this may be the unequal access to electronic resources and publications available to scholars who work within a trauma approach and those who do not. In order not to replicate the trauma bias that currently exists on the web in this guide, a number of articles, books, and papers that are not electronically available are reviewed here.

The study of war and mental health issues in psychology and psychiatry

People have known for a long time that war can have a negative effect on people's emotional, mental, spiritual, and social well-being. In many communities around the world rituals have existed for centuries that are specifically intended for combatants returning from battle to help them reintegrate into communal life. It is only in the past 150 years or so, however, with the development of psychological theories and knowledge, that this has become the concern of psychologists in the West.

The term ‘West’ refers to the countries of western Europe and North America and ‘Western’ refers to ideologies and approaches to psychological knowledge that originate in these countries.

Summerfield (2000) points out that prior to the development of psychology as a discipline the suffering, distress, and illness caused by armed conflict had been considered primarily spiritual or religious affairs rather than medical or psychological issues.

Psychological practitioners

This includes all people who work in the area of mental health, for instance social workers, psychologists, psychiatric nurses, counsellors, psychiatrists, community mental health workers, etc.

became interested in alleviating the effect that exposure to and participation in armed conflict has on people from the late nineteenth century onwards. In World War I many soldiers suffered from symptoms that could not be explained by physical injury. This illness came to be known as 'shell shock', as the doctors believed that the shock from exploding shells was responsible for the illness (Leys 1996). Later on, with the development of psychological theory and greater attention to the emotional and mental problems of the soldiers in World War II and of survivors of the Nazi concentration camps, doctors concluded that there were psychological reasons for why people became ill after very distressing experiences.

It was the Vietnam War veterans, returning from the Vietnam War to the USA from the 1970s onwards, who focused attention on the issue of the psychological consequences of armed conflict on people (see PTSD). Since then it has become generally accepted by psychological practitioners that the experiences of war can have a negative impact on the emotional and mental well-being of people and that it is the duty and responsibility of mental health workers to address these (Young 1995) . How this has been done has varied greatly and will be discussed below.

In communities around the world it has long been recognized that participation in warfare can cause difficulties and problems for the combatant and his or her family. These difficulties are, however, different from the ones presented by psychology and psychiatry and may include having to appease restless and vengeful spirits of civilians unjustly killed in warfare, or the reincorporation of a soldier into a community. In Angola and Mozambique, for example, purification rituals are performed for returning soldiers so that they may be reincorporated into their communities. In Native American communities returning soldiers underwent sweat lodge rituals which are seen both as spiritual and physical purification ceremonies but also as opportunities for personal growth and healing (Wilson 1989) .

Historically, there are thus many different understandings and conceptualizations of the social, personal, and health-related consequences of participating in warfare. These will be explored in the following sections.

Websites
Honwana 1991 http://ccrweb.ccr.uct.ac.za/archive/two/8_1/p30_collective_body.html
Leys 1996 http://www.uchicago.edu/research/jnl-crit-inq/v20/v20n4.leys.html
Summerfield 2000 http://tps.sagepub.com/cgi/content/abstract/37/3/417?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&author1=summerfield&searchid=1107958214379_65&stored_search=&FIRSTINDEX=0&sortspec=relevance&volume=37&journalcode=sptps

Development of psychosocial assistance as part of the humanitarian aid regime

Over the last two decades humanitarian agencies providing assistance to war-affected populations have increasingly paid attention to the psychological and social impact of violent conflict and displacement on communities. The physical and material conditions of displaced groups have always been considered the mandate of humanitarian agencies but it was only from the mid-1980s onwards that organizations began to see the provision of forms of psychological assistance to large-scale refugee displacements as part of their agenda as well.

There are several reasons for this. One is the way in which psychology has become popular in the media and public conversations in the West. Psychological explanations are frequently used in relation to people's problems and experiences in television talk shows, movies, and in newspaper advice columns. The word 'trauma' in particular has become part of everyday language in many Western countries, where people talk about experiences as having been 'traumatic' or someone having been 'traumatized' as a consequence of death, divorce, illness, or accident (Bracken et al. 1995) . In the wake of the attacks on the USA on 11 September 2001, 'traumatization' has become a household word in that country as information is provided to the public about what symptoms they and their children may expect to have as a result of the 'trauma' they have experienced (Ehrenreich 2002) .

A related reason for the popularity of the concept of trauma in the West is the idea of post-traumatic stress disorder (PTSD) and the way in which psychologists and psychiatrists use it not only to explain the behaviour of the Vietnam veterans, but also the reactions of people to distressing life events or natural disasters such as hurricanes, earthquakes, and fires (see, for instance, the International Society for Traumatic Stress Studies).

Another reason is that as more refugees came to European and North American countries after World War II, attempts were made to integrate them into the host societies. Medical centres providing medical services to the refugees and asylum seekers noticed that some of their clients had long-term illnesses that seemed to be caused primarily by emotional pain rather than by physical illness or injury (Eisenbruch 1992) . These long-term illnesses made it difficult for the refugees to adjust to life in their new countries. Medical practitioners tried to provide psychological help to some refugees who not only were suffering from 'culture shock', but who were also trying to cope with the memories of what they had left behind as well as experiences of death and suffering.

These experiences contributed to humanitarian agencies becoming concerned about the emotional and psychological well-being of forced migrants. They argue that focusing on the priorities of human survival such as safe water, food, and shelter should not mean that mental health is of less importance (Marsella et al. 1994) . The international aid community has a responsibility to address the psychological and emotional dimensions of the refugee experience.

This thinking led to a proliferation of psychosocial projects in conflict zones in the early 1990s, particularly in response to the wars in the former Yugoslavia and the genocide in Rwanda in 1994. Summerfield (1996) states, for instance, that 185 psychosocial projects were operating in areas of the former Yugoslavia in 1995. The implementation practices of such projects are diverse, with some focusing predominantly on providing psychological services, for instance counselling for individuals or groups, while others placing more emphasis on social assistance through community development (Strang and Ager 2001) .

Some critics argue that the popularity of psychosocial work with war-affected communities and displaced people has led to the growth of a 'psychosocial industry', similar to the humanitarian aid industry, relying on professional 'experts' from the West to develop trauma programmes for populations in the south (Parker 1996) . These and other criticisms will be discussed in more detail in some of the sections below.

Websites
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
Eisenbruch 1992 http://216.239.35.100/search?q=cache:lzCNbuJucm8C:www.dinarte.es/salud-mental/pdfs/Eisenbruch-From%2520PTSD%2520to%2520cultural%2520bereavement.pdf+Maurice+Eisenbruch+cultural+bereavement&hl;=en&ie;=UTF-8
International Society for Traumatic Stress Studies http://www.istss.org/
Strang and Ager 2001 http://www.ishhr.org/conference/articles/strang.pdf

Definitions: what is psychosocial work?

What exactly does the term 'psychosocial' mean and what is meant by psychosocial assistance or work? Are these substitutes for mental health and providing psychological help? Or does the term 'social' mean that anything that improves the general well-being of war-affected communities can be counted as being psychosocial?

It seems that every organization answers these questions differently, depending on which approach it takes. As has been said, psychosocial projects vary greatly and include anything from therapy sessions to building communal structures where people can meet and conduct their community affairs. Ahearn (2000) notes that there is little agreement in the field as to what psychosocial assistance is or should be: different organizations emphasize either the psychological or the social aspects, but also have different understandings of what each of these terms mean. Many different psychological theories exist about how to help people who have had distressing experiences. For example, cognitive psychologists believe that influencing thinking processes is important, psychodynamic psychologists believe that reactions are caused by unconscious impulses, and system theory psychologists believe that the social environment of the person is the most important aspect of how they cope with experiences. More information about these different psychological approaches can be found in Loughry (2001) .

It has been suggested that the concept of 'psychosocial' should be linked with 'well-being', in other words that people's psychosocial well-being is part of their general health (Ahearn 2000) . The World Health Organization (WHO) defines health as 'a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity' (Ahearn 2000: 4) . Most definitions of the term 'psychosocial' are based on the idea that a combination of psychological and social factors are responsible for the well-being of people, and that these cannot necessarily be separated from one another. The term directs attention towards the totality of people's experience rather than focusing exclusively on the psychological aspects of health and well-being, and emphasizes the need to view these issues within the interpersonal contexts of wider family and community networks in which they are located. Ager (2001) , for example, describes psychosocial interventions as the integration of social and psychological approaches to the prevention of mental health problems and social difficulties.

The definition used by Baron (2002) is one that was agreed in the 1997 Regional Workshop in Kenya and states: 'The word 'psycho-social' simply underlines the dynamic relationship between psychological and social effects, each continually influencing the other.' Baron points out that this suggests that each person is made up of an integration of the following:

the mind, thinking, emotions, feelings, behaviour are the psycho or psychological components

the social world which creates the context through the environment, culture, economics, traditions, spirituality, interpersonal relationships with family, community and friends, and life tasks.

Websites
Ager 2001 http://earlybird.qeh.ox.ac.uk/rfgexp/rsp_tre/video/toc_tr.htm
Loughry 2001 http://earlybird.qeh.ox.ac.uk/rfgexp/rsp_tre/student/brief/paradigm/par_p1.htm
Last updated Aug 17, 2011