Building resilience in the face of unrelenting trauma

Three tukuls - A girl’s creation in a child friendly space of an IDP camp in Juba, South Sudan. (Photo: Carmen Humboldt © SRC, 2015)

Having gained independence in 2011 after a decades-long struggle, South Sudan is currently convulsed by a complex humanitarian crisis, with more than 3.5 million people displaced internally and in neighbouring countries (UN OCHA, 2017), their hopes for a better future dashed by the eruption of fresh fighting at the end of 2013. As various elites fought for control of resources and power, the situation quickly hardened ethnic fault lines, driving rifts into various segments of government and society. Entire communities fled, most with hardly anything, to United Nations bases known as “protection of civilian” camps. Although initially envisioned as short-term solutions, the camps remain home to 218,000 people, some of whom are unable to venture outside the gates owing to security concerns. Many more remain internally displaced elsewhere in the country or live as refugees in neighbouring nations.

A myriad of underlying issues

Myriad underlying issues have spawned a wide range of psychosocial problems in South Sudan’s population. Exposure to the prolonged pre-independence conflict, with people either displaced, living as refugees in neighbouring countries, or enduring the hardship of living in a country at war, is the main basic cause. Some of today’s middle-aged men in South Sudan were conscripted into the military as child soldiers during the war of liberation, and children continue to suffer as child soldiers in the current conflict. Exposure to violence has left many suffering mental disorders such as post-traumatic stress disorder, depression and anxiety. (Roberts et al., 2009) Their plight has been compounded by the simmering ethnic tension exposed in the renewed conflict pitting members of different ethnic groups against each other. The combination of insecurity, economic stress, lack of basic services and the inability to engage in normal activities has driven parts of the population to antisocial behaviour such as alcoholism, drug abuse and crime. Sexual and gender-based violence is used as a weapon of war, but it is also a consequence of the hostilities. Within the protection-of-civilian camps, overcrowding and poor lighting create conditions that can increase the risk of sexual violence, predominantly towards women and girls. The change in living conditions brought about by displacement often causes substantial psychological and social suffering in the short term; if not properly addressed, this can lead to long-term mental health and psychosocial problems (DCR, 2014).

South Sudan: Red Cross volunteers promoting activities with children in the Melijo IDP camp. (James Mwanza © SRK, 2014)

Addressing psychosocial issues is all the more difficult in that the stressors are constantly present, and part of the population is convinced that some of the issues would dissipate once certain underlying stressors, like war and hunger, are dealt with. The fact that the political and economic outlook remains bleak does little to alleviate the mental health situation of the population.

In South Sudan, access to mental health care is generally poor

The lack of qualified personnel, for basic services and for specialized management of specific cases, is another major challenge when it comes to providing psychosocial support to people marked by war and violence. According to the World Health Organization (WHO), in 2014 South Sudan had only ten mental health workers providing in- and out-patient care (WHO, 2014). The National Health Policy 2016–2025 clearly lists as one of its sub-objectives to build health system capacity for counselling, treatment and rehabilitation of patients with mental illnesses. It is hoped that this will include resources to provide psychosocial support to communities.

Account from South Sudan
To some, it is just an empty plastic bottle; waste that has completed its task of carrying clean water deemed safe. Not for these two young boys, around 10 years old, who fight viciously over the bottle that one of them has just acquired. Smaller boys, around 6 years old, gesture at the fighting duo with their perfectly crafted mud models of AK-47s, half cheering the fight on, half threatening to stop it with their “weapons”. Eventually the bigger of the two boys emerges victorious while the smaller boy is left dolefully nursing scratches on his arms. The cheering boys grin excitedly and point their toys in the air as if shooting celebratory fire. This is just another day for these boys, children emulating the adults around them and re-enacting the present they know and the future of combat that they believe is theirs. These children know only poverty and war, having experienced nothing else. They are stuck in a vicious cycle, unaware that some people live lives devoid of poverty and war – the kind of poverty that gives special meaning to an empty plastic bottle.

Coping with emotional distress

Founded in 2011, the South Sudan Red Cross (SSRC) is a young National Society. Its local branches and network of 8,800 volunteers are nevertheless able to reach most parts of the country, except where access is hampered by the conflict. It was prompted by the high needs to establish its own department for psychosocial support. Within the scope of its country programme, the Swiss Red Cross contributes to SSRC capacity building in this area, and a main aspect of its health project for internally displaced people and their host communities is psychosocial support.

In camps for internally displaced people, the SSRC provides a child- and youth-friendly space where children can play and express themselves through art and theatre, as a way of working through traumatic experiences. Young people who engage in theatre take the sessions back to their communities, communicating various messages, including on gender-based violence. Some of the art sessions are therapeutic in purpose, allowing children to express themselves and relate to their current circumstances and their place in the world. In dealing with these issues, cases of mental health disorders in need of specialized treatment are often encountered.

South Sudan: Internally displaced family in the settlement of Minkamen (© SRC, 2014)

The provision of psychosocial support has also been integrated into health projects in South Sudan to ensure that the whole spectrum of health, encompassing both physical and mental health, is catered for. According to a study on post-conflict mental health in South Sudan, “Psychosocial interventions in the form of assistance from religious groups, friends, family and tribal structures, are some of the most important tools to help patients with depression, post-traumatic stress disorder and anxiety feel better.” (Amesekere and Henderson, 2012) Therefore, as a first step, the SSRC heightens community awareness of psychosocial issues, their signs and symptoms, and of coping mechanisms. A forum has been established to give communities an opportunity to discuss such issues and benefit from peer-to-peer support. Lay counselling is provided in some cases, and assessments are conducted of how to best develop supportive structures in the community.

As a way of addressing some of the root causes and effects of the prolonged strife in the country, the SSRC provides community education on gender-based violence, alcoholism, drug abuse and child abuse, including child marriages; the aim is to change behaviour so as to reduce the incidence of trauma within the community. The SSRC also provides services for women and girls at risk of gender-based violence, either directly in the form of psychosocial support or through advocacy among service providers and institutions.

Children in a primary school playing football in the frame of psychosocial support provided by a SSRC volunteer. (Photo: James Mwanza © SRC, 2014)

Persistent challenges

Need for professional psychological services

Activities in the child- and youth-friendly spaces and in the communities are facilitated by Red Cross volunteers mentored by SSRC staff. The volunteers are often confronted with cases that require management by a professional. As the next level of care is lacking, it is difficult to set up a referral pathway. Improving the referral system for psychosocial services calls for coordination with other stakeholders working in the same area and advocacy vis-à-vis the health authorities.

Working in fragile contexts is extremely demanding

The Red Cross volunteers and project staff working in fragile contexts are witnesses to the traumatic consequences of violence and destruction, and face cases of extreme physical and psychological stress. Many of them have also suffered emotional distress and are in need of support themselves. It is therefore critical to care for their physical and psychological well-being as well.

Ongoing insecurity and fighting in the country

The population, including the volunteers, is constantly forced to move in the face of the ongoing instability in the country. This makes it extremely difficult to ensure any continuity in the work in the communities. The evaluation of the first project phase points to the need for better supervision and mentoring of volunteers, which will require further capacity building in the area of psychosocial support at all levels of the SSRC.

Ultimately, all efforts to promote social change and resilient communities in fragile contexts are doomed to fail unless the psychosocial dimension is addressed. This requires perseverance and a flexible long-term approach.

Psychosocial support in the Red Cross
In its recently published issue paper on health programming in fragile contexts (SRC, 2017), the Swiss Red Cross stresses the importance of taking into account the psychosocial dimension when working in fragile contexts. It has opted to include this dimension in its conflict-sensitive programme management. The 2016 SRC Health Policy encourages country programmes “to assess and address the need for psychosocial support and social well-being”, two aspects that are not, however, among the thematic priorities of the SRC health programme. At present, SRC projects explicitly integrate psychosocial support in only two country programmes: South Sudan and El Salvador. In both countries, the SRC draws essentially on the approaches promoted by the International Federation of Red Cross and Red Crescent Societies (IFRC) for emergency relief work and within its Framework for Community Resilience.

The International Federation Reference Centre for Psychosocial Support in Denmark has put together a series of reference papers and training resources for community-based psychosocial support, resilience strengthening and disaster response.

The IFRC framework for psychosocial support defines such support as the process of facilitating resilience within individuals, families and communities by respecting their independence, dignity and coping mechanisms. Psychosocial support promotes the restoration of social cohesion and infrastructure.

“Psychosocial support helps people recover after a crisis has disrupted their lives. It aims at enhancing the ability of people to bounce back and restore normality after adverse events, and refers to the actions that address both the social and psychological needs of individuals, families and communities. Red Cross Red Crescent National Societies implement community-based psychosocial support interventions, which are based on the idea that if people are empowered to care for themselves and each other, their individual and communal self-confidence and resources will improve. This, in turn, will encourage positive recovery and strengthen their ability to deal with challenges in the future.” (IFRC PS Centre, 2014)

The IFRC suggests that National Red Cross and Red Crescent Societies engage in the following fundamental psychosocial support activities:
- Psychological first aid
- Lay counselling
- Peer support
- Support groups and self-help groups
- Caring for volunteers
- Psychological training
- Making referrals for specialised psychological or psychiatric treatment
- Advocacy

References

Amesekere, M. and D.C. Henderson (2012), “Post-conflict Mental Health in South Sudan: Overview of Common Psychiatric Disorders”, South Sudan Medical Journal, Vol. 5, No 2, May
http://www.southsudanmedicaljournal.com/assets/files/misc/post-conflict-mental-health%20in-south-sudan.pdf.

IFRC PS Centre (2014), Strengthening Resilience: A global selection of psychosocial interventions. The International Federation Reference Centre for Psychosocial Support
http://pscentre.org/.

Republic of South Sudan (2016), National Health Policy 2016–2025
http://www.arkangelo.org/AAA/AAA%20documents/2016%20documents/THE%20POLICY.pdf.

Roberts, B., E.Y. Damundu, O. Lomoro and E. Sondorp (2009), “Post-conflict mental health needs: A cross-sectional survey of trauma, depression and associated factors in Juba, Southern Sudan”, BMC Psychiatry, 9:7.

Swiss Red Cross (2016), Health Policy for International Cooperation, SRC, Bern
https://www.redcross.ch/de/publikationen?term_node_tid_depth_1=1133.

– (2017), Think differently and stay engaged. Health programming in fragile contexts, Issue Paper on Health Series No. 6, SRC, Bern
https://www.redcross.ch/de/shop/studien-und-factsheets/think-differently-and-stay-engaged-health-programming-in-fragile

DCR (2014), Unmet Mental Health Needs: A National Emergency in South Sudan, The Dutch Consortium for Rehabilitation
https://mhpss.net/?get=159/Unmet_Mental_Health_NeedsA_National_Emergency_in_South_Sudan.pdf.

UNICEF (2016), South Sudan Humanitarian Situation Report, No. 88, 3-16 June
http://reliefweb.int/report/south-sudan/unicef-south-sudan-humanitarian-situation-report-88-3-16-june-2016.

UN OCHA (2017), South Sudan, United Nations Office for the Coordination of Humanitarian Affairs
http://www.unocha.org/south-sudan.

WHO (2014), Mental health Atlas country profile
http://www.who.int/mental_health/evidence/atlas/profiles-2014/ssd.pdf.