Working with children in conflict: A skill-building workshop

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Working with children in conflict:
                      A skill-building workshop

Canadian International Development Agency
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Gatineau, Quebec
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It is easy to say we respect the rights of a child. It is a challenge to reflect that
principle in our work with children in situations of armed conflict. The desire to
improve skills for effective practice motivated this workshop, and we hope the learning
recorded in this report will contribute to a community of learning on this subject.

The workshop was sponsored by the Children and Armed Conflict Working Group, of
the Canadian Peacebuilding Coordinating Committee, in cooperation with the
Canadian International Development Agency (CIDA). In addition to financial support,
the assistance and interest of staff in the Gender Equality and Child Protection
Division were much appreciated.

Thanks to Jo Boyden and Mike Wessells, who shared their experience and critical
reflection to stimulate discussion. Their presentations formed the core of the
workshop and this report.

In addition to the challenge of the subject, the workshop brought together program
officers from CIDA with field staff and project managers of non-governmental agencies
for mutual learning. We want to acknowledge the contribution of the facilitators:
Kevin Bush, Hilary Homes, Jackie Kirk, Heather MacPhail, and Jennifer Shorthall.

Special thanks go to Robin Wentzell, Executive Director of Peace Bridges Community
services, who planned and coordinated the workshop to meet the needs of all the

The facilities were generously donated by The International Development Research
Centre (IDRC) as part of their on-going work in peacebuilding and post-conflict

Kathy Vandergrift,
Chair of the Children and Armed Conflict Working Group

                         Produced with the support of the
                        Government of Canada through the
                 Canadian International Development Agency (CIDA)

I     Introduction                                                             1

1. Objectives of Workshop                                                      1

2. Workshop Leaders                                                            1

3. Organization of Workshop                                                    1

4. Framework of Workshop                                                       2

5. Key Learnings                                                               4

      A. Contextually based programming                                        4
      B. Strengths and Resiliency of Children                                  4
      C. Importance of hearing from children                                   5
      D. Importance of education                                               5

II    Problem Identification, Factors Affecting Social Well-being              5
      & Mechanisms Used Within Communities

1. Children’s Experiences and Understandings of Armed Conflicts                5

      E. The role of civilians, especially children, in situations             6
         of armed conflict
      B. Physical and psychological recovery from situations of violence       6
      F. The need to hear from the children themselves                         7
      G. The children’s experience of conflict                                 7
      H. Insights from children                                                8

2. Diverse Cultural perspectives on Psychosocial Health and Well-being         9

      A. Examples of psychological reactions as a natural response to shock    10
      B. Risk and resilience                                                   10
      C. Factors mediating psychological and social development
         and well-being                                                        11
      D. Cultural ideas and practices in relation to risk, misfortune and
         psychosocial well-being                                          12

3. Tools and methods for conducting a social analysis                          13

III   Different Models and Forms of Intervention                               14

1. Mapping the Field of Psychosocial Assistance                                14

A. The different meanings of psychosocial assistance                 14
      B. Medical and community-based models                                15
         B.1 – The medical Model                                           15
         B.2 - The Community-based Model                                   19
      C. Comparison of the trauma and community-based approaches           21
      D. Project example in Angola - The PBWTT Project                     21

IV    Integrated Framework: Issues, Priorities and Implications            22

1. Psychosocial Intervention Pyramid                                       22

2. A Heuristic for Psychosocial Programmatic Intervention                  25

3. Factors Affecting Psychosocial Well-being                               28

V     Child Soldiering and Psychosocial Implications                       29

1. Problems Associated with Focusing on Child Soldiers                     29

2. Why Children Become Soldiers                                            29

3. Macro and Micro Risk Factors for Child Soldiers                         30

4. Psychosocial Impacts of Child Soldiers                                  31

VI    Intervention Goals & Suggested Activities for Psychosocial Support
      and Re-integration of Former Child Soldiers                          31

1.What would you do to start?                                              31

2. Goals or Strategy                                                       32

3. Consideration in developing a strategy                                  32

4. Types of Program Activities and Effective Practices                     32

VII   Areas for Further Work                                               33

1.Monitoring and Evaluation                                                33

2. Ethical Consideration                                                   33

3. Research                                                                33

4. Sharing Information                                                     33

                          A SKILLS-BUILDING WORKSHOP



     1. Effective implementation of assistance programs that respect the rights of
     2. Practical skill development for use in design and operation of programs.
     3. Participatory, shared learning by CIDA officers and NGO staff as a community.
     4. Lessons learned from experience, as the basis for planning and theory.


The workshop leaders were Jo Boyden on Day 1 and Mike Wessells on Day 2.

Jo Boyden is a social anthropologist with 20 years experience as a consultant for
national and international agencies, undertaking applied research, advocacy, policy
and program development, and monitoring and evaluation in the field of child
protection. Presently she is a researcher at The Refugee Studies Center of the
University of Oxford, UK, where she runs a programme on war-affected and displaced

Mike Wessells, works with the Christian Children’s Fund, U.S. and is a professor of
psychology at Randolph-Macon College in Virginia, where he teaches courses on the
dynamics of conflict, youth violence, psychological dimensions of peace and
international security. The Associate editor of Peace and Conflict: Journal of Peace
Psychology and the author of three books and over 50 articles and chapters, he
currently conducts research on the psychology of humanitarian assistance, post-
conflict reconstruction and the re-integration of child soldiers.


Focus on Day 1: Jo Boyden guided the workshop on Day 1, which focused on tools to
understand a situation from a child’s perspective, to identify factors that affect social
well-being and to support the coping mechanisms of children and their communities.
Participatory methods were applied to baseline assessment, planning, monitoring, and

Day 1 was divided into two sections:

     1. Children’s experiences and understandings of armed conflicts; and
     2. Diverse cultural perspectives on psychosocial health and well-being.

Focus on Day 2: Mike Wessells guided the workshop on Day 2, which focused
on the development of effective program responses, exploring different models
and forms of assistance, with specific application to work with child soldiers.


The Convention on the Rights of the Child (CRC) provides a framework for analysis
and exploration of effective modes for work with children in situations of armed
conflict. While all aspects are integrated into a child-centered approach, the following
articles were highlighted with particular importance for emergency situations (See
Appendix 1 for selected Articles):

     •   Article 6: the right to life and development, including social and emotional, as
         well as physical well-being;
     •   Articles 9, 10: the right to family life and family reunification when separated;
     •   Article 19: protection from violence, abuse, neglect and exploitation;
     •   Article 22: the rights of child refugees and international responsibilities;
     •   Article 28: the right to education
     •   Article 34: the right to protection from sexual exploitation and sexual abuse.
     •   Article 38: specific protection during armed conflict, including age of
     •   Article 39: physical and psychological recovery and social reintegration.

The advantage of the children's rights frame is that it enables us to see children as
actors, rather than merely as passive victims. In the psychosocial field, the CRC can
be used as a tool to provide coherence and connectivity to all children’s rights. These
rights need to be dealt with comprehensively, to ensure coherence in program design
and implementation. The CRC provides a framework for:

     •   Child protection
                • Global corrective for extreme political, social, and other abuses
                • Unified framework for action & advocacy
                • Monitoring and addressing gaps
                • Legal and ethical warrants for a focus on Child protection

     •   Holistic approach to children’s development
                 • Dynamic interplay of health, nutrition, education, and poverty
                 • Linkage with economic, social, cultural, civic, and political
                 • Integrated, multi-level approach to social and emotional

     •   Comprehensive, integrated approach to psychosocial assistance
              • Avoidance of narrow, single-strand approaches
              • Beyond symptom reduction and band-aids.
              • Necessity of inter-sectoral linkages and programs.

•   Gender
            •    The issue of gender equity is brought to center stage.

   •   Emphasis on positives
            • Focus is on strengths and entitlements, rather than deficits.
            • Avoidance of pathology and stigma.
            • Invites an analysis of existing resources and assets

   •   Child and youth participation
              • Empowerment approach
              • Children as actors, not passive victims.
              • Children as resources and supports.

The rights under the CRC are regularly violated in war situations. For example:

   •   The right to life ensured in Article 6 should not be seen only as a right to
       physical life but also as a right to mental and emotional development.
       This is extremely difficult to ensure.

   •   This can be complicated by the tension between meeting urgent needs for
       physical survival in an emergency setting and a focus on child protection
       issues.    Rapid emergency responses can create dilemmas between
       different approaches to meet the different needs.

   •   Field workers, lacking clinical psychological skills, focus on physical
       survival issues rather than the more complex issues of people's world-
       view and values.

   •   When the social fabric is destroyed by war, the Parties to the Convention
       may be incapable of implementing the special provisions for the
       protection of children separated from their families and of child refugees
       (Articles 9, 10, 21, 22.) Displacement is probably the most common
       problem. Only the tip of the iceberg is visible in the number of officially
       registered refugees. Those displaced within a country and those
       displaced illegally across borders are probably fourfold. This is a very
       serious issue.

   •   Education is one of the interventions that has a role in the psycho-social
       support to children. It structures their lives and children receive support
       from schools and peers.

   •   Historically, in times of war, education has been seen as secondary
       rather than recognized as an essential component of humanitarian
       assistance. (Article 28). However, for today's children in war torn
       countries, education is crucial for learning about security, land mines,
       and protection from sexual exploitation of both boys and girls (Article

•   While concern for sexual exploitation usually pertains to girls, it has
         been established that boys' vulnerability stems from their tendency to
         keep their sexual exploitation a secret because they feel greater shame.

     •   Children become combatants in armed conflict by State Parties to the
         Charter, contrary to Article 38, which provides for their care and
         protection as civilians, and by non-state armed groups.


A.       Contextually based programming

Effective programming for children in violent conflict is based on knowledge of
the specific situation, not built on global ideas and experiences.           For
psychosocial programs to work, they must be grounded in situation-specific
cultural knowledge and understanding.         For example, socio-centric and
egocentric cultures differ in terms of their understanding of personhood and
how a person fits into his/her social world. This has important implications for
psychosocial well-being and the type of support to be provided. In some
cultures, when reintegrating child soldiers, there is a need for cleansing rites
and rites of atonement before they will be accepted back into the community.
This type of programmatic intervention should be considered, if efficacious.

It was suggested that you cannot build a psychosocial assistance program as a
stand-alone program. People who live in poverty with extremely high needs
require some of those basic physical and subsistence needs to be met;
otherwise they think you do not understand the extent of their difficulties.
Some organizations have dealt with this perception by implementing small
economic activities that are income-generating, while implementing the
psychosocial aspects of the program.

Cultural preparation is necessary to locate local resources and utilize them. In
addition, the assessment process should not be short changed by doing a very
quick mapping assessment without understanding how the situation is
changing. In the context of war and conflict, the situation is extremely

B.       The Strengths and Resiliency of Children

We tend to view children in situations of violence as passive, helpless victims,
weak and vulnerable. However, reality is more complex. In many cases, we are
not dealing with a sick child, but one who survived the war and one who
assumed responsibility for others. Children can be very resourceful and
resilient. The challenge is to find ways of protecting and supporting children
that acknowledge their active roles and responsibilities in society and thereby
further their sense of self-efficacy.

Psychosocial intervention is about preserving what supports the positives in
the life of the child. For example, it cannot be presumed that a positive move
is to return a child to an extended family situation after the loss of the child’s
parents. Members of communities and extended families do not necessarily
have the same interests as the child, which is something we often presume in
programming. One such example is in situations when family members have
told soldiers where the young girls are located, in exchange for food.

In conflict situations, children often assume productive adult type roles but in
peacetime, they are expected to return to their position in the community as a
child. The loss of a productive role in the community becomes a key issue to
factor into programming.

C.     The importance of hearing from the children themselves

We need to hear from the children themselves about their experiences of armed
conflict. Just as cultural perspectives vary, so children's experience of conflict
often varies from what adults imagine it to be. Many programs in the past
have been designed based on what adults thought their children needed. It is
time to shift this perspective.

D.     The importance of education

Education is a key intervention because it has a role in the psychosocial
support to children. It structures their lives and children receive support from
schools and peers. Structure is important as it provides a mechanism for
getting back into daily routines and it creates a sense of normalcy.

                                         DAY 1:


Jo Boyden, Session Leader

1.     CHILDREN’S EXPERIENCES                AND     UNDERSTANDINGS           OF

The discussion on the effects of armed conflict on children, their families and
communities was framed in terms of their psychosocial well-being. Two key
points were raised:

       •    Psychosocial well-being is more than the treating of sick children, it
            calls for moving away from a narrow medical focus.

•   Effective programming for children in violent conflict is based on
          knowledge of the specific situation, including culture, history, and
          local issues, not built on global ideas and experiences.

This part was structured under the following topics:

Α.    The role of civilians, especially children, in situations of armed conflict
B.    Physical and psychosocial recovery from situations of violence
C.    The need to hear from the children themselves
D.    The children's experience of conflict
E.    Insights from children

A.    The role of civilians, especially children, in situations of
      armed conflict

It is important to understand the role of civilians and children in situations of
armed conflict, both as victims and as actors. Destruction of civilians is not
incidental to armed conflict; it is often a military objective. We tend to view
children in situations of violence as passive, helpless victims, weak and
vulnerable. However, reality is more complex. For example:

      •   Children take an active role and this affects them psychologically.
      •   They find themselves in situations which denigrate certain ethnic
      •   Children deal with security roadblocks and obstacles to free
      •   They need to continue their everyday lives in the midst of violence,
          witnessing homes, food stocks and people destroyed, often including
          their own.
      •   They fulfill economic roles such as childcare and domestic chores that
          strain their competency.
      •   Recruited as child soldiers, they are deprived of positive social and
          familial values and their socialization is framed in violence.

B.    Physical and psychosocial recovery from situations of violence

The term "psychosocial" emphasizes the dynamic, reciprocal relationship
between psychological and social experience.

      •   ‘Psycho’ refers to emotions, behaviour, thoughts, beliefs, attitudes,
          perceptions and understanding of an individual.
      •   ‘Social’ refers to a person’s external relationships and to the influence
          of the environment (family, school, peers and local community) on
          his/her well-being.1

 UNICEF Northern Uganda Psycho-Social Needs Assessment (NUPSNA),
November 1998, page 3

We need to consider cultural variability and what "psychosocial" and "well-
being" may mean in different cultures. Questions to ask include:

      •   What is the local cultural meaning of recovery?
      •   What does social reintegration mean from the point of view of the
          child and the child’s community?
      •   What local social structures have been damaged and what must be
          restructured in order for society to be "right" again?
      •   What local cultural resources—healers, for example—are available to
          aid in the process?
      •   What are the different ways in which people need to recover?

C.    The need to hear from the children themselves

For problem identification and baseline assessment, we need to hear from the
children themselves about their experiences of armed conflict. Just as cultural
perspectives vary, so children's experience of conflict often varies from what
adults imagine it to be. Most assessments are done through interviews with
adults, rather than children.

The reasons why adults cannot grasp what the children experience and the
risks they face are as follows:
       • Adults may be feeling shame for failing to protect children;
       • Children keep secrets because they do not want to add to their
          parents’ distress;
       • A depressed parent may not notice a child's trauma;
       • Teachers obligated to deal with 60 to 100 children cannot know what
          an individual child is going through;
       • The ways in which children think about and integrate their
          experiences may also be different from adult interpretations;
       • Therefore, children's views should be integrated into baseline

D.    The children's experience of conflict

How children think about and interpret their experiences has a major impact on
their psychosocial well-being. The children’s experience of the conflict includes:
       • Family separation and bereavement;
       • Disruptions to social networks and to care and protection
       • Destitution, poverty, unemployment and material loss;
       • Service disruption and loss;
       • Threats to physical integrity and security;
       • Sexual violence;
       • Exploitation;
       • Threats to cultural and spiritual life and to cultural and social

•   Massive change in division of labour, roles and responsibilities within
             the family and community;
         •   Displacement.

E.       Insights from children

From the stories of children in Appendix 2, key insights can be gleaned, such

     •   Children are involved precisely because they are children. They are often
         actively involved in conflict because they are actually committed to the
         cause. They have specific attributes, which make them useful in a war.
         They are used for intelligence gathering, as the eyes and ears of the
         army. For example, the Khmer Rouge used children to spy on their own

     •   Soldiers know they can use children, for it is well established that a child
         with a gun is more brutal and ruthless than an adult.

     •   Girls from restrictive societies (e.g. Muslim countries and the Maoist
         regime), experience a form of liberation by being a girl soldier and often
         play a bigger role. This overturns hierarchy in a positive way and so the
         girls want to remain as soldiers.

     •   Girls are more prone to apathy and depression after the conflict is over,
         for they are no longer allowed to go out and have to resume their
         previous gender roles. This happened to girls who participated in the

     •   Being a girl soldier, conventionally viewed as totally negative, gives girls
         access to social power, as well as to food, clothing, and companionship,
         all of which are positives. Psychosocial intervention is about preserving
         what supports the positives in the life of the child.

     •   Girl soldiers often do not see themselves as exploited or violated. In fact
         they have walked out of programs that use this language. Loyalty and
         skills learned in war need to be developed. One example of positive values
         acquired through conflict was seen in El Salvador where girls of 12 to 14
         years entered the army and received an education at night.

     •   Even though they show signs of post-traumatic stress disorder (PTSD),
         often we are not dealing with a sick child, but one who survived the war
         and one who assumed responsibility for others.

     •   Members of communities do not necessarily have the same interests,
         which is something we often presume in programming. There are winners
         and losers in conflicts and we do not know who did what to whom. For
         example, in Uganda, men in one community survived by trafficking girls
         to soldiers. These men, who traded information about girls for food, were

known to the girls and were often neighbours or even family members.
         The gravest threat to girls came from within their own community. In Sri
         Lanka, the children thought that it was safer to play in the jungle where
         there was a risk from wild animals, than in their own community.

     •   Children can be very resourceful; for example, the survival technique of a
         young girl in Kosovo was to dress and act like an old woman for added

     •   It is often everyday experiences that traumatize children, for example, the
         taking of cattle. A small boy in charge of the cattle feels responsible for
         the starvation of the community because he was looking after the cattle
         when they were taken away. He feels he allowed it. This is more of a
         burden than death. A child who is forced to defecate in a food pot, or
         could not prevent it, is similarly consumed by guilt.

     •   Education loss can be significant for those who would normally have
         received it. The loss of a productive role in the community is also key,
         and we need to factor this into our programming for intervention. For
         example, a cowherd boy who lost his cattle in war will not find going to
         school after the conflict is over a positive experience. He has forfeited his
         role as a productive member of society and perceives that he cannot,
         therefore, successfully make the transition to adulthood. His perception
         of what happened to him is important to his reintegration as a socially
         responsible participant.

     •   One of the phenomena of conflict is that children take on leadership
         roles. Yet, in a post-conflict situation, adults expect them to revert to
         their roles as children. And when children fail or refuse to revert, they
         are treated as criminals. Psychosocial programmes aim to change the
         views of the community concerning its children and their needs. This
         includes the need to fund programmes for young men who are often
         distressed by social dislocation, unemployment and often the shame of
         returning home, having lost the war.


War poses many threats to children’s psychosocial health, well-being and
development. The effects of exposure to highly detrimental events and situations
vary widely in individual children and over time. Many children, especially in
the short-term, experience very distressing psychological reactions as a natural
response to shock.

         This section looks at:

     A. Examples of psychological reactions as a natural response to shock
     B. Risk and resilience

C. Factors mediating psychological and social development and well-being
     D. Cultural ideas and practices in relation to risk, misfortune and
        psychosocial well-being

A.      Examples of psychological reactions as a natural response to
        shock include:

        •   Nightmares;
        •   Sleep difficulties;
        •   Physical symptoms (headaches, stomach aches, bed wetting);
        •   Withdrawal;
        •   Elective mutism;
        •   Difficulty concentrating;
        •   Exaggerated fears/worries;
        •   Hypervigilance.

With support from family, friends etc., most children will overcome most of
these distressing reactions through the "natural" healing process of time.
However, the more adversities children experience, the more likely it is that they
will have difficulty overcoming these distressing reactions. A small percentage
of children are likely to remain in difficulty in the longer term and may need
more focused help

B.      Risk and Resilience

Children’s individual responses to adversities such as armed political violence
have been described in terms of “risk” and “resilience”. “Risk” refers to
variables that increase an individual’s likelihood of psychopathology or their
susceptibility to negative developmental outcomes. Some risks are found
internally; they result from the unique combination of characteristics that
make-up an individual, such as temperament or neurological structure. Other
risks are external; that is they result from environmental factors, such as
poverty or war, which inhibit an individual’s healthy development.

Not all children exposed to risks develop problems later on. These children are
deemed resilient. The term “resilience” refers to an individual’s capacity to
adapt and remain strong in the face of adversity. Resilience depends on both
individual and group strengths, and is highly influenced by supportive elements
in the wider environment. These positive reinforcements in children’s lives are
often described as “protective factors” or “protective processes”. The effects of
these protective factors are shown only in their interaction with risk.

One program objective could be to increase resilience in children.

While it is understood in the literature that risk and resilience are not
constructed the same way in all societies, it is generally accepted that the
interaction of risk and protective factors plays an important role in the social
and psychological development of all children.

In this sense, child social and psychological development is not a mechanical
process but mediated by a range of risk and protective factors

C.     Factors mediating psychological and social development and

Psychological and social development and well-being, are mediated by a
range of factors, such as:

i)     Factors to do with children themselves:

       •   Individual traits (i.e. genetic predisposition—temperament, physical
           health, etc.);
       •   Age and developmental capacities;
       •   Social status (children in different categories are perceived and
           treated differently, therefore develop different competencies and
       •   Personal history.

ii)    Social, material, economic and environmental factors:

       •   Degree of social unity and trust within family & community;
       •   Secure attachment to care-giver (s);
       •   Positive relationships with family and peers;
       •   Presence of mentor/positive role model & leadership;
       •   Meaningful role & learning opportunities;
       •   Service access;
       •   Physical & material security;
       •   Economic security.

iii)   Cultural values and practices as factors that mediate psychosocial well-

       •   Healing involves making sense of distressing events and experiences,
           assimilating and processing grief, anger or anxiety.
       •   While healing may be an intensely personal process, individuals
           experience misfortune not as isolated beings, but in socially mediated
           ways that are shared.
       •   The meaning, and thus experience of violence, family separation, and
           other adversities is, in significant measure, culturally determined.
       •   Different cultures have very different strategies for managing risk and
           adversity and for protecting their children.
       •   Introducing child protection approaches and strategies that do not
           reflect and build on local perspectives may jeopardize children

Examples of the various categories of factors that mediate psychosocial
development and well-being were explored in plenary and are attached as
Appendix 3. In this discussion, it was confirmed from the participants'
experience that psychosocial programmes must be grounded in situation-
specific cultural knowledge and understanding.

Attached, as Appendix 4, is a checklist of priority problems and factors used in
the Northern Uganda Psycho-Social Needs Assessment (NUPSNA), Nov.1998.

D.      Cultural ideas and practices in relation to risk, misfortune and
        psychosocial well-being

Cultural ideas and practices in relation to risk, misfortune and psychosocial
well-being vary greatly. For example:

i)    Socio-centric and egocentric cultures differ in terms of their
understanding of personhood and how a person fits into his/her social world.
This has important implications for psychosocial well-being and the type of
support we give:

        •   In egocentric societies, an individual exists as a discrete entity and
            social autonomy is a major goal.

        •   In socio-centric societies social relations are understood as the
            central factors in individual health and illness. The body is seen as a
            unitary, integrated aspect of self and social relations. It is dependent
            on, and vulnerable to, the feelings, wishes, and actions of others,
            including spirits and dead ancestors. The body is not understood as a
            vastly complex machine, but rather as a microcosm of the universe.2

        •   Accordingly, who you are in the social order and the roles and
            responsibilities assigned to you are everything. In such societies
            persons are not autonomous as individuals and do not exist
            independently of the social group to which they belong. Your social
            status (e.g. as eldest son, mother’s brother, youngest daughter, etc.)
            defines your roles, duties and responsibilities. Fulfilling your role
            ensures your social integration and sense of self-efficacy and self-
            esteem. This applies to children as much as to adults.

        •   Fulfilling your familial and social duties is an important goal even in
            war and explains the motivation behind most personal action, e.g. the
            voluntary recruitment of children.

        •   When you cannot fulfill these duties and responsibilities (e.g. when
            war cuts children off from their productive roles) psychosocial health
            and well-being may be in jeopardy.

2   Scheper-Hughes and Lock, 1989, p. 21

•   The challenge is to find ways of protecting and supporting children
          that acknowledge their active roles and responsibilities in society and
          thereby further their sense of self-efficacy.

ii)    In many cultures, misfortune (including the misfortunes of war) is
perceived as being caused by the intervention of powerful others - social,
natural, or supernatural forces. Hence, disease is often portrayed as resulting
from the malevolent forces of nature, spirits or deities. Thus, for post war
reintegration and reconstruction of the social fabric, the issue of burial rituals
and other rituals for the dead are vital for ‘normalisation’.

Resuming normal life involves appeasing and honouring the spirits of the dead.
For example in Angola (and other parts of Africa) life does not end with death
but continues as the dead pass on to another dimension (Monteiro and
Honwana). At the burial of the dead, the spirit remains as an effective
manifestation of the power, personality and knowledge of that person in society.
Spirits of the dead have powerful influence over the living, both positive and
negative, and therefore must be venerated through prayer and ritual
performance. Spirits can protect you during war or punish you for neglecting
them, for example, through failure to bury them or to observe rites at their
burial site.

iii)   Symptoms and signs of distress occur universally in violent conflict, but
are interpreted very differently in different cultural contexts and some may not
have much meaning in some contexts. For example, hypervigilance, is viewed
as an effective survival strategy in many war zones since it keeps people alert to
the dangers. In many communities dreams are seen as part of concrete reality.

iv)    Social mechanisms of forgiveness, healing and reintegration following
active involvement in conflict may exist in many societies. For example,
cleansing rites and rites of atonement and reintegration for former combatants
where these are efficacious should be supported by programmatic interventions.


Group work provided the opportunity to use useful tools and methods for
conducting a social analysis, as part of a baseline assessment and problem
identification. The tasks are outlined in Appendix 5



Mike Wessells, Session Leader


There are as yet no well-worked out strategies for mapping the field of psychosocial
assistance. Rather, we are at the edge of forming such strategies. We can start with
two distinct approaches – the medical model and the community-based model. These
two approaches are polar opposites. The trauma healing approach operates on ideas of
mental illness, whereas the community-based approach employs a more holistic
concept of well-being. Activities arising out of each approach are therefore different.

Different perspectives exist between the field worker and donor agencies and between
the mental health and community well-being models. The ongoing challenge is to
determine whether these perspectives and models can be integrated. A comparison of
medical and community-based models shows their implications for practical program
decisions and allocation of resources.

This section of the report looks at:

A.      The different meanings of psychosocial assistance
B.      The medical and community based models
C.      A contrast and analysis of the two approaches
D.      A practical example of a psychosocial program implemented in Angola

A.      The different meanings of psychosocial assistance

i)      Critical social perspective on psychosocial assistance

Community-based psychosocial assistance has a broader perspective and is
culturally specific in nature. By comparison, the psychopathological trauma
approach is more narrowly constructed. It was noted that:

        •   Views of mental health and psychosocial well-being are culturally
        •   Approaches to psychosocial assistance are also cultural products.
        •   The trauma approach is grounded in the cultural dominance of
            Western, northern categories and assumptions.
        •   The psychosocial approach recognizes the limits of universalized

ii)    Forms of psychosocial assistance

       The following forms of psychosocial assistance can be used:

       •   Family integration of separated children;
       •   Building tolerance;
       •   Reintegration of child soldiers;
       •   Strengthened legal protections;
       •   Education;
       •   Nonviolent conflict resolution;
       •   Family violence prevention;
       •   Trauma healing;
       •   Positive parenting support;
       •   Solidarity enhancement;
       •   Support for women’s groups;
       •   Healing rituals;
       •   Stigma reduction;
       •   Normalizing activities;
       •   Helping the helpers;
       •   Peace education;
       •   Linkages with health, poverty reduction;
       •   Role enhancing activities;
       •   Counselling;
       •   Support for youth;
       •   Expressive activities.

iii)   Key issues for programmatic intervention

       •   Resource allocation;
       •   Power imposition;
       •   Damage assessment;
       •   Participation and dialogue across cultural boundaries, recognizing
           power asymmetries.

B.     Medical and community- based models

B.1    The Medical Model

i)     Medical model applied in a war zone: core assumptions

The following assumptions exist behind the trauma approach as a medical
model and its construction of Post-Traumatic Stress Disorder (PTSD):
      • War experiences produce trauma and related psychological
          dysfunctions, such as depression.
      • Traumatic experiences may occur before, during, and after armed

•   Trauma shatters one’s sense of security and place in the world; PTSD
          leaves adults overwhelmed, debilitated, emotionally numb, and ill
          equipped to help their children.
      •   Trauma overwhelms children’s resilience and capacities for coping,
          leading to a host of negative (age-related) outcomes.
      •   Trauma is a normal response to extreme, life-threatening events.
      •   Long-term hyper-arousal and neurological changes associated with
          PTSD are universal; delayed expression may occur.
      •   PTSD does not heal spontaneously.
      •   Unhealed traumas help fuel cycles of violence.
      •   Technically competent psychologists and psychiatrists are needed to
          assist healing and emotional integration following armed conflict.
      •   Healing occurs mostly through emotional expression and processing
          in a safe, supportive context.
      •   Western tools need to be culturally adapted to the local context.

ii)   Assessment of post-traumatic stress disorder (PTSD): exposure to

PTSD can be induced by directly experiencing traumatic events, or by
experiencing them vicariously (source: Dinicola, 1996).

Directly experienced events are those such as:
       • Violent personal assault (including sexual assault);
       • Kidnapping and hostage situations;
       • Exposure to violence (attack, destruction of home, landmines, etc.);
       • Life-threatening experience through deprivation.

Vicariously experienced events may be personally witnessed events like:
       • Death;
       • Serious injury;
       • Sexual assault;
       • Dead bodies or body parts.

Or events experienced and conveyed by significant others:
      • Violent assault;
      • Serious injury sustained by a family member;
      • Learning about sudden death of a family member.

Using the term PTSD can lead people to think they are going crazy. It is
important to communicate that what they are experiencing is normal and
universal. Assessment on the PTSD scale is mechanistic and it does not take
into account that culture and social ecologies mediate to help people come out
of PTSD. In the case of children, it is better not to take the pathology approach
because children are resilient. The PTSD scores also do not indicate what,
exactly, is causing the greatest stress. For example, when an eleven-year-old
child’s parents were killed and her house destroyed, it was found that her
greatest stress was that she did not bury her parents.

iii)   Assessment of post-traumatic stress disorder: symptom criteria in

The following symptoms of PTSD are manifested in children exposed to violent
conflict (source: Dinicola, 1996):

a.    Child experiences events that would be markedly distressing to almost

b.     Re-experiencing phenomena
       • Intrusive recollections/images;
       • Traumatic dreams;
       • Repetitive play;
       • Re-enactment behavior;
       • Distress at traumatic reminders.

c.     Psychological numbness/avoidance
       • Avoidance of thoughts, feelings, locations, situations;
       • Reduced interest in usual activities;
       • Feelings of being alone/detached/estranged;
       • Restricted emotional range;
       • Memory disturbance;
       • Loss of acquired skills;
       • Change in orientation toward the future.

d.     Increased state of arousal
       • Sleep disturbance;
       • Irritability/anger;
       • Difficulty concentrating;
       • Hypervigilance;
       • Exaggerated startle response;
       • Autonomic response to traumatic reminders.

iv)    Trauma interventions

The programmatic aspects of trauma intervention were detailed as follows:
      • Assessment and cultural tailoring;
      • Facilitation of grief and bereavement;
      • Counselling;
      • Expressive activities;
      • Psycho-educational workshops;
      • Training and capacity building;
      • Community sensitization on mental health;
      • Strengthening referral networks;
      • Facilitation of positive social relations.

Trauma-focused intervention suffers, however, from a narrow focus by
categorizing problems from a medical perspective.

v)     Strengths of trauma-focused interventions

Within this context, the positive strengths of trauma intervention are:
      • Scientific foundation, so empirical data is more readily available;
      • Relatively well-defined indicators and assessment tools;
      • Alleviation of pain and suffering;
      • Community awareness of those who need special assistance;
      • Strengthened capacities for supporting mental health;
      • Attractiveness to donors and communities.

vi)        Weakness of the trauma focus

       •    Scale of problems and paucity of clinical, professional assistance;
       •    Enabling of "victim" mindset;
       •    Cultural inappropriateness - limits of centers, talking approaches,
            individualized intervention;
       •    Communal wounds require communal healing;
       •    Need for holistic approaches;
       •    Need for empowerment, social mobilization, political reconstruction;
       •    Excessive resourcing of trauma research and interventions in war
       •    Failure to connect healing with wider reconstruction tasks such as
            building tolerance;
       •    Poor sustainability.

vii)   The trauma focus - conceptual issues

The trauma approach treats individuals affected by violence apart from their
social context. Such a "stand-alone" perspective differs in significant ways from
the community based psychosocial approach. For example:
       • What is "post-" about the conflicts?
       • Continuous stress;
       • "Disorder" and medicalization of political, economic, and human
          rights problems;
       • Universalism- Does PTSD apply and is it linked with social
          dysfunction in cultural context?
       • Local meanings and phenomenology;
       • Spiritual dimensions;
       • Individual vs. communal wounds;
       • Power asymmetry - imposition and imperialism;
       • Marginalization and self-silencing of indigenous practices and

The medical approach marginalizes local methods of stress alleviation and
healing, while the community-based approach reaches out for the wider
context, systematically taking socio-political aspects into account.


The goals of community-based psychosocial programming are very different
from those of the medical approach. For example:

      •   It looks for strengths and resilience in the particular community and
          seeks to enhance family supports for children’s resilience,
          competencies, and coping capacities;
      •   It aims to support vulnerable children and families;
      •   It assesses not only the medical risks but also the macro-social risks
          such as poverty and the micro-social risks such as child beating and
          child sexual abuse;
      •   It aims to reduce risks to children, families, and communities;
      •   It recognizes that the vulnerable, such as children who are alone and
          the poor, are at greater levels of psychosocial risk, rather than seeing
          them as being at a greater level of "sickness";
      •   It aims to protect children’s rights at all levels.

i)    Sample of desired outcomes

The desired outcomes of community-based psychosocial programming are a
sense of belonging and a positive identity for the marginalized groups. It focuses
on increasing hope within the community through the development of positive
future options such as:
       • Strengthened community mechanisms of child protection;
       • Increased development of age-appropriate competencies;
       • Secure attachments with caregivers;
       • Meaningful peer attachments, friendships, and social ties;
       • A sense of belonging and positive identity;
       • Increased tolerance;
       • Access to and success in school;
       • Increased hope and positive future orientation.

ii)   Assumptions of community-based approaches

 Several assumptions behind the community-based psychosocial approach
 serve to broaden the baseline assessment for programmatic intervention.
       • War shatters human rights and social supports, increasing risks and
           protection needs. Trauma is a very small part of the impact of war on
       • Children’s response to traumatic events is mediated by their beliefs
           and perceptions, social ecologies, and culturally constructed values
           and practices.
       • Psychosocial assistance should be holistic, culturally grounded, and
           oriented towards well-being rather than deficit-reduction.
       • Intervention strategies are social rather than individual and should
           benefit the entire community.

•   Effective programming requires a systemic approach that
           interconnects supports for children, families, communities, and peer
       •   Children are not victims but actors whose participation contributes
           significantly to psychosocial support. They are a resource for the
           community’s task of re-building.
       •   Local cultural practices may be important sources of resilience,
           coping, and protection.
       •   Local families and communities are not vacuums—they have existing
           resources for supporting children’s well-being.
       •   Program design, implementation, and evaluation are community-
           driven and participatory and engage local knowledge and resources.
           Emphasis is on community empowerment and collective planning,
           and action on behalf of children.

iii)   Limits of the community-based approach

It is difficult to document the impact of community-based intervention due to
lack of empirical tools to measure it. So far in its development, the community-
based approach is potentially limited by:
        • Weak documentation of impact
        • Stigmatization of vulnerable groups through excessively targeted
            assessment or programming
        • Poorly defined causal pathways
        • Reified concept of “community”
        • Privileging particular groups
        • Excessive reliance on expatriates
        • Cultural scripts & gender bias
        • Planning & delay program implementation
        • Imposition of outsider approaches to resilience, child development,
            children’s rights
        • Asymmetrical assistance


                              TRAUMA APPROACH                  COMMUNITY-BASED
Scope                         Narrow, Psychological             Broad, integrated

Goals                         Individual healing and          Community mobilization,
                               emotional integration           Healing and capacity-

Expertise                            Outsider                      Insiders, mixed

Training Orientation                 Directive                 Mutual learning, open

View of local people          Victims, beneficiaries         Actors, creative resources
Power                       Asymmetrical focused on              Shared, distributed
                            NGO and national team
Local culture
                                   Background                        Foreground
View of Western
                               Universal, privileged         Need to interweave the etic
                                                               and emic approaches

                                       Low                              High


The Province-Based War Trauma Training (PBWTT) project was provided as an
illustration of a project that dealt with psychosocial assistance. The PBWTT
project was conducted in Angola with USAID support and the collaboration of
UNICEF, the Angolan government, NGOs and churches. Seven provinces were
selected, and 4,000 adults were trained, by the province based training teams.
The trainees were selected by their own communities as being leaders on behalf
of children and well situated to help them. The trainees were first identified in a
meeting with the local Chief and the council of elders – all men. The next step
was to meet with groups of influential women and to find within their
community those who were the leaders on behalf of children.

Attached, as Appendix 6, is a helpful blueprint of how this type of training
project could be designed. It provides: 1) Background statistics; 2) Goals; 3)
Outcomes; 4) Method; and 5) Process. With regard to the PBWTT training
seminars, it provides information on 1) Content; 2) Methodology; 3) Follow-up;

4) Evaluation Methods; 5) Gaps and constraints; and 6) Impact of the PBWTT

Observations from the PBWTT project:

     •   Flexibility is required when it is determined that donor or agency defined
         indicators do not serve the local needs.
     •   Many players go into these contexts with a plan already in place, arriving
         with a pre-conceived checklist, which may not be relevant in every
         conflict situation.
     •   There is a silencing of the regional voices when international organizations
         come onto the scene.
     •   The single biggest problem with both techniques is that if there are too many
         westerners on the team, there is not enough power sharing and empowerment
         of the local members of the team.
     •   Local people “self silence” and will often defer to Westerners, with their
         university degrees.
     •   Western trained locals can be more Western in their approaches than
     •   Scientifically not a lot is known regarding what works.
     •   You need to find and connect with local NGOs
     •   In program development and design, we tend to use our own models.
         Stimulating linkages with locals is more valuable and more sustainable.



The psychosocial intervention pyramid provides a framework to identify those
children who are at high risk, middle risk and low risk. A draft Psychosocial
Intervention Pyramid, designed by The Working Group on Psychosocial
Assistance, Save the Children U.S., is shown on page 24.

The most severely affected people at the top of the pyramid require the more
focused, exclusively targeted approach. The standard figure for prominent PTSD
is somewhere around 10 to 20%. The common assumption is that individuals in
this most-at-risk group require some sort of specialized individual interventions,
which is particularly a westernized view. However, even the specialized focused
interventions such as therapy and counselling do not have to be at the
individual level. This can be done through interventions that provide mutual
assistance and strengthen community networks, for example, through the
existing structures such as youth and church groups, etc.

In the middle of the pyramid you will find a much larger group, which may
consist of separated children, former child soldiers, and individuals who have

experienced sexual violence. Working within a risk-resilience framework and
from the community based standpoint, the point of entry and the intervention
would be at the social, not the individual level. The project approach at this
point consists of group interventions to strengthen the changing social ecology.

The standard approach is to reunite the members of the extended family.
However, sometimes this is not the best approach. For example:

   •   These children often have become exploited labour by the extended
       family and sometimes quite marginalized by them; and

   •   There are a lot of 13-18 year olds who can provide excellent support and
       who are actually much more capable as a competent, and emotionally
       accessible “parent” than lots of 20 or 30 year olds.

At the base of the pyramid is the largest group of people who may be war-
affected but may exhibit greater resilience. They have demonstrated the ability
to survive and have significant functional capacity. For this group, you need to
strengthen educational activities, skills development, and perhaps some
economic opportunities. The project approach is not individually focused but
community-based and includes health education, economic activities, and a
return to basic normalizing activities within the context of social and cultural

Effective psychosocial assistance cannot be delivered to people whose stomachs
are empty. Arriving in a four-wheel-drive vehicle prepared 'to deal with the
wounds of war", when people are struggling to meet basic physical survival
needs, will not impress them positively. You cannot think about responding to
these issues one at a time. You have to think about vertical integration, to
develop interventions that work simultaneously at various levels and that
interconnect across the levels. This could include dealing with material issues,
such as small income generation projects, to convey an understanding of their

The post-conflict environment leaves people isolated, marginalized, hungry, and
torn apart by community violence. When that happens, people can slide from a
low risk group in the pyramid up to a higher risk group.


                                 Target Population
                                High-Risk Groups
                                 Project Content
                              Individual Counselling
                                Project Approach
                            Individual interventions to
                        Strengthen individual functioning

                                  Target Population
                                  At Risk Groups
                                  Project Content
                Family reunification, Social reintegration, Healing-
            rituals, Reintegration of child soldiers, Support to Parents
                                 Project Approach
         Group Interventions to strengthen trust, tolerance, and healing

                                 Target Population
                                  Low Risk Groups
                                  Project Content
        Educational activities, Skills development, Economic opportunities
                                 Project Approach
Community-wide Approaches to offer health, education, and economic opportunities
   Prevention of further harm, Restoration of basic developmental opportunities

This model does not really capture the richness of local culture, social ecologies,
and power structures in the conflict-affected communities, with all the different
networks and constituencies that exist at the grass-roots level. The values and
background culture and agendas of outside agencies - donors, engineers, etc -
may not fit with the local culture.


To develop a model that is more culturally appropriate, the Christian Children's
Fund, Save the Children in the US, International Rescue Commission, MSF
Holland and a number of academic partners have been working together with
medical practitioners over the past few years, to institutionalize the field of
psychosocial assistance and enable the maturing of the field. The heuristic is
found on the next page. The following three questions/needs were considered to
develop a framework that could accommodate various kinds of social

     1. What has been learned from previous social interventions, and what are
        some of the key gaps that we can identify?

     2. What is the scope of research activities conducted in partnership with
        the NGOs and academic institutions to address these gaps?

     3. The need to create a research agenda for donors to specify the kinds of
        outcome studies which could be developed and be useful in developing
        the field systematically.

The Heuristic below, as well as Appendix 9 “Factors Affecting Psychosocial
Programming in Complex Emergencies”, are draft materials prepared by the
Mellon Psychosocial Working Group.

This is a group product, seeking very practical, grass-roots sources to develop a
heuristic for thinking about psychosocial programmatic interventions. The team
is composed of three groups: academics; community-based practitioners; and
public health experts.

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