the war within - tdrp programming in ddr.ppt.pdf · •psychosocial impacts of extreme violence on...
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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
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 - 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 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