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C OMMUNITY M ENTAL H EALTH AND W ELLBEING : A C ASE S TUDY J ANAKA J AYAWICKRAMA, PhD S EPTEMBER 2010 Community-University Collaborations: Exploring Models, Sharing Good Practice Durham University

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G ENESIS UNHCR partnership to evaluate mental health and wellbeing interventions for refugees in Malawi. Additional accompanying field work was conducted with support from UNHCR.

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

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R ATIONALE TO THE S TUDY 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.

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M OST I NFLUENTIAL L ITERATURE NameSubject Derek 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

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M OST I NFLUENTIAL L ITERATURE NameSubject Lao Tzu circa 100 BC Tao Te Ching Ancient Knowledge Walpola Rahula 2003 Compassion, Uncertainty and Danger Religious TextsDifferent Perspectives on Life, Mental Health and Wellbeing Folk StoriesDifferent Traditional Knowledge Perspectives on Wellbeing

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M AINSTREAM L ITERATURE B ODY Clinical Psychology and Trauma/ PTSD International Standards and Practice Wellbeing 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)

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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 Positivist Critical Realism Subjectivism ? THE RESEARCH PROCESS (Source: Author)

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FROM PRACTICE TO POLICY (Source: Author) 2. Qualitative: Key interviews 1. Quantitative: Evaluations Policy Programme Practice Evaluation Criteria (Adapted from OECD) 1Theoretical basis / Relevance 2Coverage 3Efficiency 4Effectiveness 5Impact 6Community 7Sustainability Burden of delivery Burden of policy Different research steps 3. Literature review and secondary readings on policies

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M ALAWI 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.

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E VALUATIVE J UDGEMENT Criterion 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

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E VALUATIVE J UDGEMENT Criterion 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

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E VALUATIVE J UDGEMENT Criterion 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

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E VALUATIVE J UDGEMENT Criterion 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

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E MERGING T HEMES PopulationEmerging 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

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D ISCUSSION : C OMMUNITY P ERSPECTIVE 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

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W ELLBEING T IME 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

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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 Source: Author

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B IBLIOGRAPHY Collins, A.E. (2009) Disaster and Development, Routledge Perspectives in Development Series, London Craig, D., Porter, D. (2003), Poverty Reduction Strategy Papers: A New Convergence World Development, 31(1), 5369 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

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B IBLOGRAPHY Jayawickrama, 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

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B IBLIOGRAPHY 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

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J ANAKA J AYAWICKRAMA, PhD C OMMUNITY W ELLBEING P ROGRAMME D ISASTER AND D EVELOPMENT C ENTRE S CHOOL OF THE B UILT AND N ATURAL E NVIRONMENT N ORTHUMBRIA U NIVERSITY j.jayawickrama@northumbria.ac.uk j.jayawickrama@northumbria.ac.uk