The War Within “Those who cannot remember the past are condemned to repeat it.”

Conference on History and Experience of Post-conflict Reintegration and Stabilization AU, AfDB, TDRP Tunis, 05.-06.06.2013

Dr. Harald Hinkel (TDRP, World Bank)

• Identifying Psycho Social Issues in DDR • Psychosocial Impacts of extreme Violence on Ex-

Combattants–and on Communities • Surveying PS issues • Challenge to success of reintegration • Addressing Psychosocial Issues – Programming MDRP –

IDDRS towards standardization • Psychosocial Modules in DDR Programs • Conclusions and Lessons Learnt • Recommendations

Outline of presentation

• Unstable Minds, Unstable Peace Observation that some beneficiaries do not

adequately respond to well-intended assistance and subsequently lose their benefit, they are unstable, they fail to reintegrate

Feeling that elements of behavior “are not normal” Looking into what is not normal (research, learn) Piloting leads to finding out how address by trying Implementing by overcoming resistance against

addressing

How we get there…

What it is: Psycho AND Social Needs

Psychosocial needs vary according to individual experiences and context

By AVSI

Psychosocial Functioning

PSYCHO: refers to the inner person – one’s thoughts, feelings, attitudes, values and beliefs. SOCIAL: refers to the person’s external relationships with his/her environment. FUNCTIONING: refers to the daily tasks, behaviour and duties a person has given his/her individual role, context and background.

Resilience

RESILIENCE: refers to the individual resources and experiences – everything a person can, has and is

By AVSI

Mental Health Disorders

Is a Greek word for “wound” applying both for body and soul.

Psychological “trauma” is the experience of events that are life- threatening or include a danger of injury so severe that the person is horrified, feels helpless etc.

TRAUMATIC EVENTS might cause a medical condition that requires treatment (therapy)

most frequently PTSD, but co-morbid with other disorders

Trauma = Traumatic Event

• a traumatic event has occurred (precondition)

• it is re-experienced in at least 1 way

• 3 symptoms of avoidance

• 2 symptoms of increased arousal

• symptoms are present for at least 4 weeks

• Symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning

Diagnosis of PTSD

I had just left a pub It was shortly after midnight

At that time I was living in Torit COLD

sensoric cognitive physiological emotional

dark night

empty street

smell of alcohol

It hurts!

I can‘t do anything!

shame

fear

despair

Fast breathing

Heart beating

HOT

sweating

man with beard

horror

anger

nausea

Why doesn’t anybody help?

Memory representation of a traumatic event

fear

strong heartbeat

shivering

stick

shame

smell of alcohol

Will it end?

Why is he doing this?

Body position

guilt

Mother screaming

water

It hurt‘s

I can‘t do anything

fear fast breathing

Sound of wave

horror

trembling

Why is nobody helping us?

sister‘s doll sweating

aeroplane

I will die!

Where should I hide anger

despair

Feeling dizzy

blood

head ache

nausea

temple

Lifeline

Psycho-education

Lifeline & Drawing of the lifeline

Narration of the whole life story

Focus on the detailed report of traumatic events

- Integration of sensory information,

emotions, thoughts, and bodily of the traumatic

situation

- Reintegration in the autobiographic

memory

- Report of the traumatic situation until the

experience of relief

- Repeated reading of the narration

intending at habituation

Narrative Exposure Therapy (NET) - Procedure

PTSD &

National Comorbidity Survey (Prigerson ‘01)

Combat trauma vs other trauma:

- Highest risk of PTSD (41%)

- Frequently associated with unemployment (3.5x)

- Frequently associated with divorce (2.5x)

- Frequently associated with violence against spouse & others (2.4x)

Veteran survey 2002 (http://www.vvnw.org)

• 300.000 US veterans homeless (on any given night)

• 60% of the homeless in the US are male veterans

• 35% of the ever in life imprisoned in the US are Vietnam Veterans

Further:

• Alcohol and drug dependence (Mogapi ‚04; Odenwald et al. in press)

PTSD and Dysfunctionality in US (ex-)combatants

Surveying Psychosocial Issues in DDR

1. Somalia

• Pre-Disarmament Target Group Assessment (active militia, 2004)

• Advantage: Earliest possible entry point, =very beneficial to DDR

planning, well developed questionnaire, well trained enumerators

• Disadvantage: Accessibility difficult, planning only based on

estimates

Surveying Psychosocial Issues in DDR

2. Burundi

• Immediate-Post-Disaramament Target Group Assessment (active

militia, 2004) … good practice

•Registration at demobilisation entry point (XCs, 2004)

• Advantage: Timely still adequate entry point, enhanced accessibility,

planning based on real figures, well developed questionnaire, well

trained enumerators

• Disadvantage: data availability for planning delayed = planning and

implementation arrangements on shorter notice

Surveying Psychosocial Issues in DDR

3. Democratic Republic of Congo (DRC)

• Post-disarmament registration at demobilisation entry point (XCs,

2005)

• Advantage: tbi

• Disadvantage: Delayed registration due to political and security

issues, difficulties with access, no developed questionnaire, no trained

enumerators, planning and implementation arrangements on

extremely short notice, very little psychosocial assistance delivered

Surveying Psychosocial Issues in DDR

4. Rwanda

• Post-Demobilisation Target Group Assessment (XCs, ongoing & in

review process)

• Advantage: Screening process undertaken by medical professionals,

fully mainstreamed process (ideal case from DDR perspective)

• Disadvantage: Late service delivery, time-consuming & cost-intensive

process, little focus on changing intake

•A story to tell: dramatic change in combat situation in 3rd country leads to need

to adjust programmatic approach towards emergency response in a country in full

swing of development work

Surveying Psychosocial Issues in DDR

5. MDRP & Rwanda

• Policy Framework (Regional, national & DDR specific, TCG – MDRP,

2007)

• Regional harmonization of mental health / trauma concepts

• Development of national policy on mental health / trauma

• Development of a DDR strategy on mental health / trauma

• Advantage: Development-oriented, sustainable, national ownership,

fully mainstreamed, DDR leads national policy development

• Disadvantage: Time- & resource-consuming long process; did not

work due to too diverse political and socio-economic conditions

Examples from World Bank Mission

Question: Can we copy psychosocial programs targeting formerly abducted youths in Northern Uganda and carry them out in South Sudan & DRC?

Interviews with formerly abducted children and youth in Yambio & Dungu

• PTSD: 20% (=Uganda)

• Depression: 10% (<Uganda)

• High Risk of Suicidality: 10% (<Uganda)

LRA: Previous TDRP Mission, 2010 An example how it can look like….

Example - Comparisons LRA: World Bank Mission - Results

Winkler & Hinkel, 2010

Example - Comparisons LRA: World Bank Mission - Results

Winkler & Hinkel, 2010

Example - Comparisons LRA: World Bank Mission - Results

Winkler & Hinkel, 2010

Example - Results

• Rates of PTSD were comparable in all countries individual Trauma therapies are needed for 20%

• Stigmatisation in DRC and South Sudan was significantly higher than in Uganda group-based interventions/awareness raising strategies

• Revenge Feelings in DRC and South Sudan was significantly higher than in Uganda group-based interventions (e.g. conflict resolution trainings) to reduce revenge

LRA: World Bank Mission - Suggestions

Approaches to Addressing Psychosocial Issues

The Case of S o m a l i l a n d

• Intervention: Development of PS Pilot Module (XCs, 2001)

• Psychological Rehabilitation (NET)

• Medical Rehabilitation

• Social Reintegration & Community Sensitization & Participation

• Economic Reintegration Support & Food Security

• Inter-Agency Coordination & Collaboration

• Advantage: Holistic approach

• Disadvantage: Pilot only

Example of PS Modules in DDR Programming: The Challenge of Reintegration – learning by doing

Economic Reintegration Package

• Businesses pre-assessment

• Family household index

• Participatory discussion

• Preparation of Business Projects

• Disbursement of assistance

• Follow up and monitoring

Business Management Training

• Income generating ideas

• Feasibility study

• Marketing

• Planning

• Costing/Pricing

• Book keeping

Psychosocial package support for the caretakers and mentally sick beneficiaries

• Socio-economic assessment

• Nutrition and Hygiene training for the caretakers

– Nutrition

– Hygiene

– Khat

Psychosocial / Homevisits

• Cooking demonstration

• Hygiene

• Conduct feedback meeting

• Counseling

• Physiotherapie

• caretaker workshop (self-help grp building)

Monitoring & Evaluation

• Household/Family Index

• Body-Weight Index

• Business Monitoring

• Medical Assessment

• Psychosocial Assessment

The Challenge of Reintegration –

Organisational Programming

The Target Group: “support to mentally challenged

Experiencen from the “Preparatory phase for expanded demobilisation activities in Somalia” project (EC/GTZ) 2003

Support to vulnerable groups: case study Somaliland pilot

DDR Programming for vulnerable groups - PS issues

MDRP/TDRP and IDDRS – Towards Standardisation

•The 2003 MDRP DDR stakeholders workshop for the GLR in Kibuye, Rwanda focused on the regional coordination of M&E and MIS. •Trauma and psychological concern are main issues that need to be identified (TGA) with adequate screening tools, and framework •Strong recommendation to integrate modules in all central database levels across the program in all member countries and follow up with M& E methods.

MDRP

Example of PS Modules in DDR Programming: The Challenge of Reintegration – Standardization

IDDRS recommendations • Psychosocial support in all DDR programs • To conduct screening during demobilization • Start provision of services at demobilization (encampment) • Psychological treatment (therapy) • Attention to special needs groups • Psychosocial Support at all stages of DDR

Example of PS Modules in DDR Programming: The Challenge of Reintegration – Standardization

The Case of Rwanda

• Intervention: adjustment of ideal case module to remerging

emergency setting imported from the region

• reintroduction of upfront assessment at reception centres (UN

and RDRP)

• Medical screening and Rehabilitation by mainstream services

• Social Reintegration & Community Sensitization & Participation

• Economic Reintegration Support

• Inter-Agency Coordination & Collaboration

• Advantage: Holistic approach – ideal but impacted by conflict relapse

Example of PS Modules in DDR Programming: The Challenge of Reintegration – flexible programming

Example - Results

1. Psychological dysfunctioning is an effect of violence and its effects on humans can impair them

2. Numbers of psychologically effected amongst exposed is significant and may be as high as 50% or beyond

3. Psychosocial needs vary according to individual experiences and context and tend to be complex – therefore copy and paste from other programs or guidelines cannot be more than an entry point

4. Programmatic attention and flexibility are paramount to success 5. Important challenges are lack of awareness and understanding by

actors, stakeholders and the target group 6. PS issues need to be identified and addressed through provision

of psychosocial assistance and treatment (rehabilitation) as otherwise reintegration into civilian society is at risk to fail and return to violent conflict a likely scenario.

Example of PS Modules in DDR Programming: Conclusions and Lessons Learnt

Example - Results

1. Programmers and implementers need to be competent and well equipped to identify and address PS issues

2. TGA/survey needs to be done as early as possible to allow to take its findings into account in the program/project planning phase. Best is a pre-disarmament assessment.

3. TGA/survey will capture facts pertaining identification of persons with special needs, their registration for tracing and follow up, referral to competent service providers or setting this up, professional treatment and follow-up, best practice will establish and assure care takers providing assistance. Society preparation, sensitization and participation are crucial for success.

4. Provision of psychosocial assistance is not enough, treatment is a must as reintegration into civilian society is at risk to fail otherwise.

5. Key PS challenges to be treated are: PTSD, Depression, Drug abuse and Appetitive Aggression. Treatment is feasible in stand alone DDR operations in extremely volatile and poor post conflict settings.

6. Programs need to offer a variety of specialized, flexible support for mentally vulnerable groups, examples are: pension, handicapped housing, physical medical rehabilitation and psychosocial support and mental health treatment, besides the usual economic reintegration assistance support

Example of PS Modules in DDR Programming: Recommendations

Example - Results

…for your attention!

Thank you….