International Crisis: Can It Really “Help” to Try to “Help”?

It is natural to feel helpless while watching images on television of humanitarian crises or natural disasters from around the world. The needs are so great, and the devastation is beyond our imagining. Whether it is pictures of rubble in Port au Prince, Haiti, flooded towns in Tennessee, cities racked by violence in Libya, or the rising black waters of the tsunami that washed over Japan, these scenes remind us of the fragility of life and the desperate needs of so many. We know that there many physical necessities such as medical care, shelter, food, and clean water. Yet we may also be struck by the deep horror and grief we see in the faces of those in the media images. And we want to help.

In the last two decades, the global humanitarian aid community has begun to create programs to address psychosocial needs in communities affected by humanitarian crises. But what might be the impact of attending to emotional needs across global and cultural boundaries? We risk inserting Western understandings of emotional difficulties, psychopathology, and psychotherapy, and we risk “helping” in a way that isolates and stigmatizes those who are hurting. As we step into this complexity, it is critical to ask the question, “can it really ‘help’ to try to ‘help’?” Fuller Seminary is in a unique position to join the dialogue of this question; the School of Intercultural Studies represents an institution committed to effective intercultural communication and relationship, and the School of Psychology seeks to train clinicians and researchers in scientifically grounded and culturally relevant practice. My own journey at Fuller as a student and a faculty member includes narratives of the unique and common needs in crisis.

I arrived in Monrovia, Liberia, in the summer of 1992 during a brief time of peace in the midst of the Liberian Civil War. I had just completed the second year of the clinical psychology doctoral program at Fuller, and I was spending the summer with the Swiss NGO Medair, supporting a program designed to help child victims of the war violence. I was hoping to collect data for my master’s project in the School of Psychology, and I wanted to see how mental health work could happen internationally. The couple leading the Medair team were friends of mine from earlier missions experience. Doug Balfour, team leader, was prepared to manage a health and vaccination program. His wife, Ann, was a clinical psychologist. The two were quite surprised to find that when they arrived in Liberia, everyone wanted to talk with Ann, the psychologist. There were so many children struggling with the effects of the civil conflict, and there were so few programs designed to meet these physical, behavioral, and emotional needs. Medair joined the humanitarian community in trying to figure out how to offer psychosocial support in this context of civil war.

During the time I spent in Liberia, I worked with an incredible team of Medair volunteers, as well as five local Liberians committed to caring for the young orphans of the war. I came to the country with a basic knowledge of trauma reactions developed from a Western perspective, and quickly saw the limitations of those ideas. I was in the perfect position as a student then, and the Liberians were willing to tell me when I was wrong, or offer alternative explanations! One “tale” going around the NGO community was that a large international organization had hired an expert consultant to complete a needs assessment of the community of children living in Monrovia. During visits to local schools, this consultant noted that the children kept their eyes downcast and did not make eye contact. The consultant concluded from this behavioral observation that the children were withdrawn, and therefore depressed. The local NGO workers quickly dismissed anything this professional had to say, since they knew that within the Liberian culture, it would be disrespectful for the children to make eye contact with an unfamiliar adult.

The work that I was involved with in Liberia nearly twenty years ago centered on training those who were working with children, and trying to understand some of the impact that the experience of war and violence had on children’s emotional health and behavioral reactions. We could see that there were regressive behaviors (bed-wetting, clinging to adults), posttraumatic behaviors (nightmares, jumpiness, worry), yet there were also many experiences that the children described of a more spiritual nature (seeing their dead parents visit them). One of the local counselors that I was working with also helped me to understand that posttraumatic symptoms such as flashbacks were interpreted within a local spiritual framework. Remembering the experience when you did not want to was understood as evidence that your enemy had put a curse on you and was causing you to remember the bad things he had done.

Another key experience has remained with me as a unique example of the opportunity to integrate faith, service, and mental health knowledge. While working with a particular orphanage in the capital city of Monrovia, Liberia, the local Liberian counselors began to hear that several of the children had recently gone without food. As they inquired further, we discovered that the mother of the orphanage had kept food from some of the kids. When we asked her about this plan, she explained that the staff of the orphanage were struggling to figure out how to have enough dry bedding for the children. The children slept on pieces of uncovered foam. Now that it was the rainy season, whenever a child wet the bed during the night, it was impossible to get the foam mattress clean and dry. So many children were wetting the bed, the staff was overwhelmed. The mother of the orphanage prayed that God would show her what to do to help the kids. She felt that his response was that the children should fast, and that this would keep them from this bad behavior of bed-wetting. The challenge for us as Western NGO workers was to honor the orphanage mother’s desire to seek God’s help and affirm her intent to support the children. However, we also talked with her and her staff about ways that children act when they are afraid (including bed-wetting). This was a tenuous moment of relationship and respect, and we sought to bring some “knowledge” from the Western context that could help explain the experiences of these children and lead to new ways to solve the problems.

One of the other questions for psychosocial programming is whether mental health needs in the aftermath of a crisis are really worth the attention. Perhaps focus on the physical necessities would create the safety and structure needed for individuals to move forward. At the core of these questions is the basic truth that the majority of people experiencing a crisis or trauma will not develop a chronic negative emotional reaction.

When the earthquake happened in Kobe, Japan, in 1995, I was still a student in the School of Psychology, and a School of Intercultural Studies student, Sue Plumb (now Sue Takamoto) organized a team of Fuller students from all three schools to travel to Kobe and work with local churches in training and earthquake relief. The team was only there for a week, but the experience was a reminder of the importance of advocacy for mental health needs. The physical needs were obvious, and they were primary. However, one aspect of the aftermath of the earthquake that surprised me was the ways that culture interacted with seeking support. For example, one young female pastor that led a local soup kitchen for earthquake survivors came to a training that we held during an afternoon. We talked about common reactions to disasters that had been seen in other settings, and she nodded in agreement as we described feelings of fear, withdrawal, nightmares, and irritability. As we talked about ways that people might cope with these experiences, she disclosed that she had lost the entire contents of her apartment, and no one knew. She was focused on caring for the church and the survivors in the community. As a leader, there was no place for her to talk about her own losses. The Japanese culture frowns on drawing attention to oneself or one’s needs.

Our brief time in Kobe was likely more of a positive learning experience for our short-term team than it was a critical lifeline of support for the earthquake survivors we met and interacted with. We arrived in Kobe “armed” with ideas of disaster psychology and models of intervention that were intended to “fix” or “prevent” posttraumatic stress. While there were moments, such as the one mentioned above, where a common experience allowed for a sense of connection, I am not sure that we sought to understand what unique resources the Japanese culture and community contributed to movements toward recovery.

In fact, there are models of intervention for posttraumatic responses that have come in and out of clinical “favor” over the last twenty years. Attempts to “transport” Western methods of trauma interventions met with initial interest and excitement in some international crisis settings. Organizations created “certification” programs in developing countries, offering local workers an official certificate as a trauma therapist after brief trainings. Some of these attempts to provide training disregarded any local mental health capacities, and some have inadvertently created misrepresentation and incompetent practitioners. In response to a misappropriation of mental health knowledge, trauma therapists and researchers have been cautious and concerned about what types of interventions to recommend in international settings.

In an effort to distill the lessons learned from many areas of intervention and experience, Hobfoll and colleagues (2007) outlined the key areas of need for communities, families, and individuals who have experienced mass trauma: safety and comfort, social connection, necessary resources, personal or communal efficacy, and a sense of hope (p. 284). We can see that these necessary ingredients do not suggest certain types of psychological theory or intervention. In fact, they represent a respect of the community’s own strengths, social networks, and methods of creating comfort and hope. Methods of treatment that disrupt or discount the natural coping of a community or individual should be avoided at all costs!

A collaboration of several international NGOs and UN agencies developed a set of standards to guide efforts of psychosocial interventions. The Inter-Agency Standing Committee Guidelines on Mental Health and Psychosocial Support in Emergency Settings (IASC, 2007) is an invaluable resource that offers guidance in developing structures for service that respect local infrastructure, include key stakeholders in well-being (including local religious leaders), recognize the need for community-based grass-roots efforts, and limit the potential of pathologizing community members struggling in their trauma reactions.

More recently, I participated in a Fuller SOP initiative to partner with psychology faculty of the State University of Haiti; this initiative was spearheaded by Fuller Psychological and Family Services and the Office of Urban Initiatives. Two other Fuller alums, Dr. Rick Williamson and Dr. Elke Rechberger, and I travelled to Port au Prince, Haiti, in May 2010, five months after the January 12th earthquake. Our trip was intended to build relationships and create dialogue in understanding ways that we might support an effort that the State University of Haiti was undertaking to open a University-based Counseling Center. The trip was a whirlwind of Kreyol, French, and rubble. But what became the most clear was the importance of our posture of listening. The Haitian psychologists, social workers, and students had valuable experiences to share, moving stories of resilience, and impossible questions to answer. For example, one student asked, “What do I do when the man in the tent city needs more care than I can give, he is seeing things, and he tried to hurt himself? There are no doctors available, what should I say?” Other concerns centered on the needs of Haitian pastors; one psychology student commented that he could see how stressed the pastors were. They were caring for their congregations, but many had also lost their homes and loved ones. “Who should the pastors turn to?”

The IASC team sent out guidelines for understanding mental health needs in the Haitian context quite quickly after the Haiti earthquake. This material and the overall IASC Guidelines have been an invaluable reference point to challenge NGOs and local programs to create programs of respect to “build back better” the mental health infrastructure of Haiti. But, as you can see in the questions above, the resources are slim, and the needs are extensive. In fact, one area that has remained a question is how to include aspects of “spiritual nurture” in psychosocial programs in these crisis areas (Schafer). Our colleagues in Haiti talked about the ways that local spiritual beliefs impacted the ongoing fears, hopes, and actions of Haitians in every part of the country. One Haitian mental health professional described a community event that centered on drumming. He seemed uncertain as he reported that many in the neighborhood reported they felt new energy and hope since this event. It was uncomfortable for the mental health professionals to talk about rituals that had a spiritual impact.

Again, Fuller Seminary is in a unique position to participate in the thoughtful consideration of this international application of what we call “integration” in the School of Psychology. There are important ethical dimensions in incorporating religious and spiritual content into psychosocial projects hosted by humanitarian organizations. There is a clear directive in the Code of Conduct for the International Federation of the Red Cross and Red Crescent Societies that no humanitarian efforts or crisis response should be done in a way that seeks to advance a specific religious perspective. However, understanding the integration of theology and psychology can inform the efforts of aid organizations to thoughtfully consider how a community’s beliefs intersect with their psychosocial well-being. Psychosocial programs should not tell survivors “what” to believe, but an integrated program can help individuals, families, and communities understand “how” their beliefs about the disaster, about hope, and about connecting with their religious community can be part of the journey of healing (Eriksson). Following the IASC Guidelines and collaborating in effective integration may be one of the key ways that our “help” can “help” in an international crisis.

REFERENCES
Eriksson, C. “Incorporating Religious and Spiritual Needs in Psychosocial Programmes.” Intervention 9 (2011): 70–73.

Hobfoll, S. E., Watson, P., Bell, C. C., Bryant, R. A., Brymer, M. J., Friedman, M. J., . . . Ursano, R. J. “Five Essential Elements of Immediate and Mid-term Mass Trauma Intervention: Empirical Evidence.” Psychiatry 70 (2007): 283–315. doi:10.1521/psyc.2007.70.4.283

Inter-Agency Standing Committee (IASC). IASC Guidelines on Mental Health and Psychosocial Support in Emergency Settings (Geneva: IASC, 2007). Retrieved from http://www.who.int/mental_health/emergencies/guidelines_iasc_mental_health_psychosocial_june_2007.pdf.

International Federation of the Red Cross and Red Crescent Societies. “Code of Conduct: Principles of Conduct for The International Red Cross and Red Crescent Movement and NGOs in Disaster Response Programmes” (1994). http://www.ifrc.org/en/publications-and-reports/code-of-conduct.

Schafer, A. “Spirituality and Mental Health in Humanitarian Contexts: An Exploration Based on World Vision’s Haiti Earthquake Response.” Intervention 8 (2010): 121–30.

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This article was published in Theology, News & Notes, Fall 2011, “Where In the World Are We? Reflections on Fuller’s Expanding Global Reach.”