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ARTICLE
Year : 2022 | Volume
: 20
| Issue : 1 | Page : 46-57
”Peace starts with peace of mind”: Study of the intersection between postconflict trauma, peacebuilding and economic development in Northern Uganda
Marian Tankink1, Ben Otto2, Patrick Onyango Mangen3
1 PhD, Consultant Anthropological Research & Training on Gender, Violence and Mental Health, Heemstede, The Netherlands
2 BSc and Postgraduate in Project Planning & Management, M&E Manager of TPO Uganda, South Africa
3 MSc, Former Country Director TPO Uganda, now Chief Executive Officer, REPSSI, South Africa
Correspondence Address:
Marian Tankink
Independent Medical Anthropologist
The Netherlands
Source of Support: None, Conflict of Interest: None
DOI: 10.4103/intv.intv_15_21
The 21-year conflict with the Lord's Resistance Army caused terrible experiences for people in northern Uganda. After the war, people returned home but with continuing mental and interpersonal problems they have found it difficult to engage in activities that would improve their wellbeing, relationships and their community's social fabric. Disharmony on all levels appears to obstruct recovery and peaceful coexistence. This study examines an intervention implemented by TPO Uganda in northern Uganda addressing mental health challenges, conflict mediation and economic empowerment. The research consisted of 23 individual in-depth interviews and 16 focus group discussions, supported by a quantitative questionnaire completed by people who had participated in the intervention. There were strong indications that psychosocial support interventions for traumatic experiences and postconflict difficulties are essential for peacebuilding and economic development. Participants of the study were found to have considerably fewer mental complaints, better coping mechanisms to manage stress and the ability to relate in a satisfactory way with their intimate partners and family members than before the intervention. In addition, they had supportive relationships with their group members and other community members.
Keywords: economic development, mental health and psychosocial support, northern Uganda, sustainable peace
The people of the Acholi and Lango subregions in northern Uganda were subjected to an armed insurgency by the Lord's Resistance Army (LRA) from 1986 to 2007. This conflict was characterised by extensive forced migration and atrocities including mass killings, deliberate and appalling physical injury to civilians, sexual violence, mass abduction, forced recruitment (including children) and plunder and destruction of property (OHCHR, 2011).
Following the conflict, communities have tried to return to some kind of “normalcy”, but individuals, families and communities are still suffering from the psychological, social and economic consequences of these atrocities and daily violence and stressors (Levine, 2016). Furthermore, a whole generation of young people has lost the opportunity to complete their education, which has increased their vulnerability. In the aftermath of this 21-year civil war, the region has experienced a worrisome rise in suicide, domestic violence, substance abuse and criminal violence (Liebling et al., 2012; Roberts et al., 2011; Vinck et al., 2007).
According to Rokhideh (2017), humanitarian and peacebuilding (PB) interventions have significantly contributed to the reconstruction of sociopolitical and economic climate of northern Uganda. Yet, little attention has been given to supporting families' psychosocial recovery in the North, despite clear correlations between traumatic experiences and risk factors such as substance abuse, aggression and domestic violence (De Jong, 2010; Tankink & Slegh, 2017). Members of the Coalition for Work with Psychotrauma and Peace (CWWPP, 2010) concluded that to achieve sustainable peace, conflict transformation, social reconstruction and residual psychotrauma must be treated and psychosocial needs addressed. This is supported by other research findings in northern Uganda, Kosovo and Rwanda (Hamber et al., 2014; Lopes Cardozo et al., 2010; Pham et al., 2004, 2010; Vinck et al., 2007).
In 2017, TPO Uganda ─ a rights-based Ugandan nongovernmental organisations (NGOs) supporting communities and families affected by conflict, disaster and/or living in difficult circumstances ─ designed an intervention that attempted to address interrelated postconflict trauma, mental health and psychosocial support (MHPSS), PB and economic development. This intervention has been implemented in the Acholi and Lango regions in northern Uganda for over 3 years.
Linking MHPSS with Peacebuilding and Socioeconomic DevelopmentMental Health Problems in Conflict-affected Areas
The conflict in northern Uganda inflicted varying levels of traumatic stress on individuals. Long after the conflict ended, individuals still struggle to cope with violence, trauma and psychosocial problems. Conflicts are not straightforward, clearly defined events that stop after peace is announced but appear on a continuum of constantly shifting nature and intensity.
Recent research shows that 22.1% of people living in conflict-affected areas have depression, anxiety, posttraumatic stress disorder (PTSD), bipolar disorder or schizophrenia (Charlson et al., 2019). People's behaviour is mainly steered by emotions (Burrell & Barsalou, 2015; Fitzduff, 2016). Unconscious processes drive fear, trauma, memory, empathy, exclusion and humiliation. A reduction of fear, hate, anger, bitterness and loneliness “can only take place in the context of relationships” (Gutlove & Thompson, 2004, p. 142). However, mental health problems are not only intrapsychic but they are also simultaneously a sociopolitical event, a psychophysiological process, a physical and emotional experience and a narrative (Kirmayer, 1996).
The psychological effects of gender-based violence (GBV) can also remain with victims long after a conflict has ended (Meintjes et al., 2001; Zicherman, 2007). Although attention is generally given to female survivors of GBV, men also experience GBV, which must be recognised as well (Carpente, 2006). Furthermore, psychological coping mechanisms are gendered (Slegh et al., 2014, 2015; Tankink & Slegh, 2017).
The continuum of violence and trauma also impacts the next generation's identity construction, which is a vital element in the process of sustainable peace (Creary & Byrne, 2014; Richters, 2015). Communities that have not recovered or reconciled or are marginalised and victimised tend to stick to (often negative) narratives transferred from one generation to another (McGill et al., 2015).
A complicated element in the complex reality in northern Uganda is that people are not a “victim” or a “perpetrator” in a mutually exclusive role (Shnabel & Nadler, 2015). Many people captured by the LRA are both victims and perpetrators. Although the LRA returnees may consider themselves to be victims, others may perceive them as perpetrators (Akello, 2019). Daily stressors linked with poverty, violence (such as GBV) and past traumatic experiences – routine challenges people face in their current daily lives – all play a very important role (Miller & Rasmussen, 2010, 2014).
Traditional and Religious Approaches
Combining psychological and spiritual interventions aimed at individual and community recovery is an essential part of the recovery process (Machinga & Friedman, 2013). Park (2010) stresses the importance of traditional and religious rituals for community integration of ex-combatants. Spirituality teaches empathy and compassion and promotes the synergy of connecting the mind and heart as well.
In northern Uganda, there are tradition-based methods and ceremonies for reconciliation. The Langi have “kayo cuk” and the Acholi have “mato oput” rituals to promote the integration of the LRA returnee into society and encourage people to forgive. These ceremonies are systems for reconciliation and justice. Forgiveness is the core element, since punishment increases violence according to traditional leaders (Allen, 2006). Rituals facilitate social reintegration and lay the foundation for the emergence of a stable and economically sustainable community. Although traditional approaches to trauma might be culturally more appropriate than the PTSD paradigm in many situations, they too are not without problems. Whereas western approaches often emphasise individual needs rather than communal approaches common in local culture in northern Uganda, traditional approaches may also neglect individual needs by focusing only on harmony in the community.
Peacebuilding
Peacebuilding is not an activity as such, but rather a range of interrelated actions on all levels of society. The work is on justice and sustainable social, economic and political institutions, as well as relationships and the development of effective governance (Clancy & Hamber, 2008). PB is a long-standing process of encouraging people to talk with each other, repairing relationships and reorganising institutions. Everyone who has experienced conflict should be involved in this process. Understanding the root causes, finding ways of moving forward and re-establishing trust are essential conditions for PB (Sliep, 2014). Peace is more than the absence of violence (Galtung, 1996). Definitions of PB are often context-bound and can vary among NGOs, but the consensus is that PB needs a long-term commitment to adequately consider the underlying causes of conflict through structural and relational transformation (Clancy & Hamber, 2008).
The harmful effects of conflict (and the continuation of conflict) on people's mental health, and high levels of poor mental health affect the ability of individuals, communities and societies to function peacefully and well in conflict and postconflict periods. An integrated, holistic and interdisciplinary approach is more likely to be sustainable. Frasco (2019, p. 8) uses the term “quality peace”.
This conceptualises peace as relational, with a “culture of peace” marked by a social condition of trust and mutual respect …. This concept introduces issues of legitimacy and trust, with peacebuilding entailing the reconfiguration of relationships between conflict parties, civil society, and the state.
Economic Development
In the process of moving forward as a community PB, traumatic experiences and economic development are intertwined (Clancy & Hamber, 2008). Due to the mental and physical effects of trauma, people have difficulties working with others and/or have no energy and struggle to plan their lives and activities. Economic development is a serious issue in northern Uganda where people are worried about needs like land and livelihood (Rokhideh, 2017). Therefore, economic development, PB and mental health issues caused by traumatic experiences should all be addressed. As a result, TPO Uganda set out to fill the knowledge gap and generate evidence on the effectiveness of integrating economic development within PB and mental health interventions.
To summarise, for reconciliation and sustainable peace, the material and economic aspects, as well as the psychosocial and mental health dimensions of people's postconflict experiences need to be addressed (Bubenzer et al., 2017; Tankink et al., 2017).
Multisectoral Approach by TPO Uganda: Peacebuilding, MHPSS and Economic EmpowermentFrom November 2017 to June 2021, TPO Uganda implemented a range of interrelated interventions that promoted conflict mitigation and delivered reconciliation programmes in selected districts in northern Uganda. The programme was based on the underlying rationale that unattended past traumas and psychological distress, stigma and discrimination, domestic violence and GBV were all hindering peaceful coexistence among communities living in the region.
To foster and realise peaceful coexistence, TPO Uganda used a community-oriented model comprised of three, layered components: (1) improve the social functioning of conflict-affected households through the provision of psychological care, trauma support and socioeconomic empowerment; (2) support the trauma recovery and psychosocial needs of families before they enrol in economic empowerment groups and (3) strengthen communication initiatives that promote positive relations and peace messages and empower formal and informal (traditional) support structures for conflict mediation.
This approach was informed by TPO Uganda's theory of change, which is built on the hypothesis that if households are supported to overcome past traumas and psychosocial distress through psychoeducational (groups) counselling, and traditional support structures are rejuvenated to mediate/resolve disputes peacefully and communities are sensitised to experience peaceful coexistence and tolerance for common sexual GBV drivers, then communities will regain their agency, enjoy better social functioning and be able to peacefully coexist, exercise tolerance and live in harmony.
Potential participants for group counselling were identified by the local TPO counsellor and/or village health team. To identify possible mental health problems, culturally validated screening tools were used such as the WHO self-reporting questionnaire-20 (SRQ20; WHO, 1994), the Patient Healthcare Questionnaire for Depression (PHQ9; Kroenke et al., 2001) and the Post-traumatic Checklist for DSM-5 Instructions (PCL5; Weathers et al., 2013).
The Psychoeducational Treatment Group
Groups of 15 members were encouraged to participate in all interventions to build strong group bonds and social cohesion and so members would come to know each other better and support one another. Initially, psychoeducational treatment groups addressed mental and interpersonal problems and the lack of healthy coping skills, and offered opportunities to share experiences as part of group counselling. This approach enables participants to share their experiences and learn (better) coping mechanisms to manage their psychological symptoms of trauma and feelings of stress. These sessions are a combination of various educational and therapeutic stress management approaches including cognitive behaviour therapy (CBT), relaxation and breathing exercises, and safe-place exercises. Elements of narrative exposure therapy are included, and participants can share their personal history in the group. The intervention's design is a bottom-up approach and although elements of the counselling programme originated in western society, this intervention was designed to fit the local Ugandan culture and language.
The Economic Empowerment Intervention
Following the counselling session, the social worker introduced each group to an economic empowerment intervention to ensure the groups can become self-sustaining and able to meet their daily needs. Group members received a small start-up grant and were trained on how to recover their livelihood and handle their crops and/or animals. They also learned how to carefully manage their income and their day-to-day needs and save money for unexpected emergencies and economic development. Each group had a clear structure with rules and regulations, maintained records and conducted weekly or bi-weekly meetings to manage savings, loans and repayments.
Community Support Structures
TPO community support structures (CSSs), the third layer, included a combination of people who had participated in earlier groups, traditional and religious leaders, local government councils and interested individuals in the community. The CSSs engage informal groups in PB activities and have reactivated traditional approaches, but in a new way. Elements of conflict mediation help communities settle conflicts in a nonviolent way to reduce violence and activate a sense of justice. CSSs play a significant role in strengthening the role of traditional support by using consensus-based dispute resolution, which means all parties are involved in solving a conflict, instead of a leader who makes the decision and one party remains bitter and angry. This also improved the community's capacity to handle conflict and harmful practices.
In this way, TPO Uganda was able to reach many individuals in need of psychological, social and economic support. At the time of conducting this survey, the intervention had reached up to 14,400 families. The intervention was conducted in three districts each with an average population of 120,000 individuals. Specialists in MHPSS, PB and CSS/conflict mediation acted as technical advisors. They trained the social workers, who facilitated the groups and supported the beneficiaries with questions or special needs.
Research MethodologyResearch Objectives
This study describes the linkages and the intersection between PB work and psychosocial attention to trauma and related mental health problems as well as current violence and stressors, and the attendant relationships with the community members' economic situation. The study of the TPO Uganda 3-part community PB programme took place in May and June 2019.
The research questions were as follows:
How does exposure to unprocessed traumatic events impede peaceful coexistence and recovery?What is the feasibility of conducting PB work among communities that have experienced postconflict trauma without attending to related MHPSS needs?What was the result of linking MHPSS, economic development and PB?Design of the Study
Elements of “outcome harvesting” methodology were used in this study. Outcome harvesting gathers (”harvests”) evidence of what has changed after an intervention (”outcomes”) and determines whether and how the intervention has contributed to these changes (Wilson-Grau & Britt, 2012). This method is especially useful in complex situations when it is not possible to concretely define most of what an intervention aims to achieve, but rather, collects evidence of what has changed and then determines whether and how the intervention has contributed to these changes.
A desk review of the existing literature and an analysis of a 2018 baseline survey were conducted to understand the project context. The baseline contained items adapted from the WHO-UNHCR Toolkit for Assessing MHPSS Needs and Resources in Humanitarian Settings (WHO-UNHCR, 2012). This was the starting point for measuring progress and the impact indicators.
Research Team
The research team included six social workers and one monitoring and evaluation officer with support from three technical advisors and the research consultant. The evaluation started with a 2-day research team workshop to achieve a shared understanding of the aim, tools and assessment approach.
Data Collection Instruments
The qualitative approach included individual in-depth interviews, focus group discussions (FGDs) and observation of the social workers. Researchers recorded the interviews (with permission) and made detailed and comprehensive summaries of all collected information. The interviews were approximately 1 hour and FGDs 90 minutes. The participants selected the settings. The FGD participants were not individually interviewed. The qualitative investigation explored possible changes and how the programme contributed the changes. The quantitative evaluation tool was a modified version of the 2018 baseline questionnaire.
Sampling Procedure
The study was performed in Gulu, Lira, Kitgum districts and the subcounties of Awach, Lakwana, Agweng, Ogur, Mucwini and Namokora. All study participants (including LRA returnees) had participated in the TPO Uganda 3-part community PB programme and were randomly selected to be individually interviewed or included in a FGD. The quantitative questionnaire was completed by a separate group of randomly selected 85 programme participants (36 males and 49 females). There were no control groups.
In total, 23 in-depth interviews were conducted with participants from all six subcounties (10 males and 13 females). The 16 FGDs (total 152 participants) were conducted with 8 female adult groups, 6 male groups and 2 mixed young adult groups (age 15–29) from six subcounties.
Data Analysis
The collected quantitative data were analysed with SPSS statistical software and compared with the findings of the 2018 baseline study. The qualitative data were analysed with ATLAS.ti and used to find explanations for the changes and the quantitative findings.
Ethical Considerations
Ethics was an integral part of the research. We ensured that the voluntary nature of study participation was clearly understood by participants, informed consent was obtained and respondent privacy and confidentiality protected.
FindingsThe study results are presented with an emphasis on the qualitative findings, supported by the quantitative results. The findings of three research questions are presented below in order.
How does Exposure to Unprocessed Traumatic Events Impede Peaceful Coexistence and Recovery?
All interviewees had been deeply affected by the LRA conflict, mentally, socially and economically, whether or not they had been abducted or remained in the internally displaced person (IDP) camps or their home areas. There was little food, no income, alcohol abuse, many cases of sexual violence, increasing HIV infections, significant fear and loss of dear ones and property.
For many people, resettling in their original homestead was extremely difficult because they had to return to a place where they had experienced horrific events and people continued to live in fear even though the LRA was no longer active. For a long time, certain places, including farmland where mass killings had taken place, were avoided because people were afraid of the roaming spirits of the dead. The conflict had created fear and hatred that people took with them when they returned home and new problems arose.
The Psychological Impact of the LRA Conflict on the Individual, Family and Community
All people interviewed stated that they suffered from mental problems, such as nightmares, feelings of being depressed, suicidal thoughts, no appetite, aggressive outbursts and violent behaviour, alcohol abuse or no energy. In addition, they had lost hope and felt disconnected from relatives, friends and other people in the community.
People were disunited, full of hatred, anxiety and mistrust and isolated themselves. People felt significantly stressed and short-tempered. This mix of psychological and interpersonal problems created on-going conflicts in intimate relationships, among relatives and in communities. LRA returnees isolated themselves because they were stigmatised or did not know how to come to terms with their trauma, identity problems and position in their community.
Many participants mentioned that the level of domestic violence and sexual GBV had increased dramatically due to mental problems, stress and hard-living conditions. Land wrangles and aggression between parents and children began to appear. This was a significant obstacle for social reconnection within families and within communities.
My problems made me beat my children and sometimes injure them. I withdrew socially from the family and friends, which gave me feelings of isolation and depression including suicidal thoughts that disturbed me a lot. (Previously IDP male in Ogur)
For most women who returned from LRA captivity, it was difficult to become married since they were considered to be murderers and were stigmatised. Even if they managed to find a partner, it was very difficult to have a stable relationship due to their traumas or aggressive behaviour.
According to the participants, a fair number of children had mental problems as well and their parents had not been able to support them. Several young people had lost hope for education and were having difficulty socialising with other members of the community. Also, many young people had started drinking heavily or showing aggressive behaviour as a way of managing their frustration. The LRA returnees had not been socialised in their parents' families and many were unfamiliar with social rules and local culture.
Parents have had difficulty performing their parenting roles, on the one hand, because of their personal mental problems, and lack of money, food and support from relatives for parenting. On the other hand, parents struggle with their children because some children no longer obeyed their parents. Some of the LRA returnees expressed a lack of parental love for the children they had given birth to while in captivity.
We, at times, have angry outburst with these children and even call them by funny names, which are very stigmatising… we even threaten to kill our children because their fathers [rebel leaders] are responsible for our current suffering. (Female LRA returnee, FGD in Mucwini)
The Economic Impact of the Conflict
People had enormous difficulty returning to their economic activities after they came home.
Most of the household properties were destroyed…and the community, especially at the family level, was no longer united the way it used to be; even farming as the main income-generating activity in the family came down [fell apart]. (Previously IDP female and CSS member in Namokora)
The poor psychological conditions further affected people's concentration, energy and productivity. Therefore, they were unable to collaborate with other people and engage in farming or other income-generating activities. As a result of long stays in IDP camps or with the LRA, people (especially the youth) did not know how to restart their lives.
Coping Behaviour Before Receiving Counselling
None of the interviewees knew how to cope with their posttraumatic reactions, their daily stress and problems. Many coped negatively by drinking alcohol and/or engaging in risky social behaviour such as gambling. Churches tried to take a central role in supporting people to pick up their lives again, but although religion was essential for many people to survive, it was not enough for mental recovery and to feel reconnected to the community. The level of community fear was very high.
The churches also recognised the need for reconciliation. Through testimonies and sacrifices, aggrieved persons were supported to recover from traumatic events. Although community prayers for reconciliation and cleansing ceremonies were conducted to bring peace and harmony to the community, the returnees' psychological reactions to their traumatic experiences were too severe and the traditional ways of coping did not bring peace in the minds of most people.
What is the Feasibility of Conducting PB Work among Communities that have Experienced Postconflict Trauma without Attending to Related MHPSS Needs?
It became clear that the distinction between traumatic experiences during the war and postconflict traumatic experiences for people in northern Uganda was not easy to achieve. The current (economic) problems, daily stressors, violent behaviour and traumatic experiences after the LRA war are directly related to traumatic war experiences.
If you do mediation, you do not address the mind of the people, that means there is a high chance that the people still go in conflict and in their livelihood they will not manage well. But, by first addressing the mind of the people you are building peace and a good relationship between people and at the end of the day, the conflicts will go down. (Male CSS in Agweng)
Without exception, all participants stated that reconciliation and PB could not be attained if their trauma symptoms, such as nightmares, depression, lack of trust and fear had not been addressed. They also noted that their mental health problems related to their daily stressors must be managed. They considered it would be impossible to reconcile with someone if these relationships continued to be disturbed by unaddressed negative assumptions and ideas about “the other”.
According to the participants, only after people have had counselling for their mental problems and regained trust in their group members and developed strategies for handling their daily problems and stressors, would they able to take the next step and reconcile with other people as well.
Traditional, Religious and Cultural PB Approaches after the LRA Conflict
One of the aims of this project was to strengthen and rejuvenate the role of traditional structures in conflict resolution. According to several participants, the conflict had weakened traditional conflict–resolution structures that had been effective before the conflict. Clan and cultural leaders were central in these structures. Although people were trying to rejuvenate these structures, not all community members respected these leaders as they had in the past because they lacked the skills for conscious dispute resolution. This TPO Uganda programme strengthened and rejuvenated the role of these traditional structures in conflict resolution.
Many LRA returnees went through cleansing rituals when they returned home, sometimes to address their problematic behaviour and thoughts, but mostly to create a space of acceptance and forgiveness in the community. Several rituals were conducted including the aforementioned kayo cuk in the Lango culture, which aims to have the parties reconcile and live together in peace and harmony, or mato oput, used by the Acholi to reconcile people with each other. However, these traditional methods of reconciliation also bring challenges. Not everyone who has participated in the rituals has accepted responsibility for the atrocities they committed during the war. Second, mato oput requires that prior compensation has been made to the family of the deceased, but in northern Uganda, most families of the offenders cannot afford the cost. Finally, participants mentioned that their individual psychological needs were not addressed.
What was the Result of the Link between MHPSS, Economic Development and PB?
After the conflict, several NGOs and the national government started programmes to support people in northern Uganda to rebuild their lives. Most NGOs tended to categorise beneficiaries and address common problems, which did not prove to be an effective approach for addressing their psychological needs. As a result, the programmes designed to address a community's livelihood needs have not been successful.
Organisations were giving tangible materials, but some people sold them off or misused the support, because they had that inner guilt and stressful thoughts. Only if our minds are stable, do we have the resources to make us reach making money. The everyday stress and bad dreams me socially and economically, because I always lacked concentration and motivation to do any work. (Female LRA returnee in Awach)
All participants, without exception, were very positive about the three-pillar TPO Uganda programme. The psychoeducational counselling sessions enabled participants to share their experiences, cope with psychological and psychosocial issues and learn (better) coping mechanisms to manage their psychological symptoms of trauma and feelings of stress. The economic empowerment groups helped them to improve their economic situation in a way that most were now able to meet their basic requirements, for example, food, school fees and medical bills. The CSSs have reactivated traditional approaches, by using consensus-based dispute resolution. Conflict mediation and PB activities now help communities settle conflicts nonviolently, which reduces violence and activates a sense of justice.
Below, each programme pillar is addressed, showing how they are interconnected.
The Psychoeducational Treatment Group
The counselling training has really supported my feelings because I can cope with stress, depression, I have good sleep, I can now concentrate with my garden work which was almost impossible for me before. Love for others has come back and even my appetite for eating has been restored and above all energy in doing work developed suddenly. (Previously IDP male in Ogur)
The combination of various educational and therapeutic approaches in the counselling group was considered to be very important by the participants. Specific elements of the counselling often mentioned by participants were relaxation and breathing exercises and safe-place exercises.1 This approach has significantly helped participants in stress and anger management, while meditation skills have given them peace of mind. The CBT helped people to learn positive coping mechanisms, instead of indulging in violent behaviour. Sharing their own personal histories in the group and listening to the stories of the other participants has allowed all participants to learn how to overcome their fears. Their feelings of anger diminished, and they developed empathy for the other. This has helped all participants to reconnect with other people in their community.
From the field assessments, we found that groups remained united after the counselling sessions. The economic activity introduced at the end of the group counselling session also created reasonable ambitions, hope and togetherness among group members. Family members who participated together had stronger bonds and family interactions for pleasure as well as renewed friendships among families. The participants started to understand that they themselves could contribute to a peaceful society. In some cases, the counselling and consequential positive changes in the participants' behaviour and feelings had a radiant effect on their relatives.
Several people stated that “if your brain is not stable, you cannot do anything”, and they all expressed significant improvement in their mental health after the counselling sessions. These qualitative findings were supported by the findings of a quantitative survey as well. [Figure 1] shows the self-reported effect of the TPO Uganda programme on mental health by participants who completed the evaluation questionnaire (all had received the counselling intervention).
The self-reported findings were overwhelmingly positive about the programme's impact on the participants' mental health; most no longer had complaints. This underscores what the people had said in the baseline survey – there was a huge need for counselling. It was not clear if specific sessions were more effective than others or the combined treatment activities and educational intervention. It is important to mention that 30 males and 45 females (88% of the participants who completed the survey) had received medical care during the TPO Uganda programme. The types of medical care or medication prescribed for mental problems were unknown. This was an omission we did not explore.
The participants' coping skills showed similar improvement. Friendships made in the groups contributed to participants' wellbeing and improved social functioning. [Figure 2] shows the findings of the TPO Uganda baseline study on coping in 2018 on the left side, and the current (May 2019) level of coping among participants in the counselling sessions on the right side.
The level of participant self-reported low coping skills decreased from 71.3% to 1%, while the high level of coping mechanisms increased from 18.7% to 92% following the TPO Uganda programme intervention. In the past, people had often started drinking because they did not know how to cope and wanted to forget their problems for a while. Only 8/30 males reported that they continued to drink alcohol and experience problems with alcohol or drug use after finishing the counselling group. One woman mentioned that she continued to drink. These findings were not fully comparable with the 2018 baseline study, as the question items were not identical. The baseline study asked about household coping; 55% of the households had members who drank alcohol or used drugs. In the current survey, 9.4% of the participants reported drinking alcohol or using drugs.
The Economic Empowerment Groups
Many counselling groups transformed into economic empowerment groups (also called livelihood groups or village savings and loan associations [VSLA] by the participants). Because participants had been in their group for so long, discussing their psychological, social and economic situation and supporting each other (including during the economic improvement sessions), they have become very close. Because of their close relationships, they are able to peacefully solve disputes or problems among themselves and enhance their tolerance, acceptance and efforts of reconciliation.
As a result of the intervention, peaceful coexistence and socio-economic status have improved and as a result, among others, we [the community] are even operating a VSLA. Most of the groups in this village were supported by TPO, who first took them through a CBT [psycho-educative treatment group] session for therapeutic mental treatment and this empowered us economically and has encouraged us to work hard so that one is able to get some money for savings on a weekly basis; it has instilled the spirit of productivity and hard working. (Male FGD in Namokora)
Several participants stated that their poverty at home diminished through group support. An indication is the number of meals a day a household can now afford [Figure 3]. In the 2018 baseline study, only 1.1% had three meals a day and 61.1% had two. In this study, 4% of the participants had three meals a day and 57.1% had two. The number of poor families with only one meal a day decreased from 37.8% to 9.4%. These findings are quite telling about the economic effectiveness of the TPO programme approach.
The increase in economic stability was supported by the interviewed participants:
We are able to meet our immediate needs. We also help one another in terms of advice, peer counselling, economic support, etc. The VSLA group has also helped us to expand on our agricultural activities and become more productive. We can concentrate on doing our own activities with the hope of benefitting from it after some time. (Male FGD in Mucwini)
Community-Support Structures
This project approach entailed identifying existing community groups that could participate in the project intervention in several ways. Members of the CSSs were trained in conflict mediation according a “people to people” approach, but not all participated in the counselling groups or livelihood groups. Traditional leaders were incorporated in CSS with the intention of revitalising traditional systems, but with new mediation techniques. The CSS groups were coached by the TPO technical expert and social workers who also received referrals for difficult cases from the CSS members.
Most CSS groups met on a weekly basis in the subcounties. Each member comes from a specific village. In the village, people with a problem went to the specified CSS representative who would try to resolve the issue. If the CSS person could not resolve the problem, it was discussed in their CSS meetings, and a plan was developed to solve it. Most cases were about land conflicts or GBV. The CSS group brought the two parties together and made no judgement, but instead, conducted mediation to arrive at a solution respected by both parties.
The success of CSS groups in the community is that they involved various stakeholders, religious and traditional leaders, local government councils and other people; their services are free. Most participants believed that the CSS's role in mediation could have contributed to long-lasting peace within the community, because more cases were addressed at the community level. Some community members still preferred to use government court procedures, but courts were also referring more and more cases to the CSS.
The members of the CSS groups were also involved in communication platforms educating community members on the key conflict drivers to enable them to adopt peaceful approaches to conflict resolution such as mediation. Community members signed declarations of abandonment of conflict drivers such as land conflicts, GBV and alcohol consumption. By doing this, they committed to ending bad practices that destabilise peace. There were also awareness-raising activities, community dialogue sessions and cross-border dialogues for peace and other community initiatives for peace such as traditional and cultural dances, mato oput and kayo cuk dispute resolution practices. These structures were mitigating conflicts in their communities.
CSS members also identify and refer people with severe mental health problems to health centres. According to the participants, the CSS has really brought an end to bad practices destabilising peace such as child marriage, mob justice, rape and defilement.
[Figure 4] shows the number of conflict cases reported in the community. The figures from the baseline study in June 2018 are compared with the follow-up survey in 2019. The results show a significant reduction in conflict cases. In the baseline study, 80.4% of those surveyed had experienced land conflict and 70.6% GBV. The participants also mentioned a third area of tribal conflict in 14.1% of the cases. In 2019, a total of 58.8% (50) households surveyed reported that they had experienced land conflict and only 5.9% (5) had experienced GBV. Additionally, 2.4% (2) of the households admitted experiencing tribal conflicts. The survey also revealed that 2.3% (2) of the assessed households had experienced other forms of conflict like assault or substance abuse (alcoholism).
The Combination of MHPSS, PB and Economic Recovery
According to the participants, the three pillars of the TPO Uganda programme are very relevant for the community, because in cooperation, they create change within their community.
As a result of the activities here in our village, especially on peace building, mediation of disputes or conflicts, there is great improvement in peaceful coexistence. People were able to settle disputes at the community level like the violent land disputes, which did not happen here in 2018…. Now people are living in peace due to an enhanced ability in peaceful resolution of conflict as a result of the dialogues and mediations done by Community Support Structures. Peace starts with peace of mind. (Male FGD in Namokora)
Almost all participants stated that counselling is essential, because if someone is provided with economic support and/or mediation, but their psychological and interpersonal problems are not addressed, then there is a high chance that they will continue to have conflicts and not manage their livelihood well.
The programme has really helped me and some of my friends, especially the psychosocial support, counselling and emotional support. Now, I am able to see my community in a much better way, positively, and I pledge to contribute to the development of my community, do more income-generating activities, farm work and earn for myself to support my family. (Male LRA returnee in Lakwana)
The economic support is an essential part of the programme, since when people are in a better economic position, their daily stress is lowered and that is an essential part of living in harmony. The participants see direct links between the participants in the counselling and livelihood groups and the reduction of violent and unwanted behaviour such as GBV, alcohol abuse and conflict in the community.
The group members help one another in terms of advice, peer counselling, economic support, etc. Their lives have changed; they have a new view of life, and no one feels hopeless anymore. When participants were asked which of the three TPO Uganda programme interventions should be conducted first, they all mentioned psychological counselling, although they were divided on whether PB or economic development should be second. It is important as well that the participants mentioned that they are better able to cope with ongoing psychosocial stressors. The vast majority have adopted peaceful approaches when addressing conflict situations.
[TAG:2]Discussion [/TAG:2]
To our knowledge, very little empirical research exists on the effects of an integrated approach to trauma-related MHPSS, PB and economic development. The current study provides an important example of good practice in this field and the TPO Uganda programme intervention is perhaps one of the few that has managed to achieve this intersection by combining PB, MHPSS and economic development interventions. It was surprising that the results were strikingly positive. Asked for negative elements people mentioned no content aspects but questioned the selection procedure. They suggested that the community could be more involved in the selection of new counselling groups.
Unprocessed Traumatic Events and Peaceful Coexistence and Recovery
In line with the findings of the CWWPP (2010), this research found that conflict transformation and social construction are unattainable if trauma symptoms are not treated and psychosocial needs are not addressed. In postconflict areas, mental health treatment should be prioritised during the development of these postconflict areas (Charlson et al., 2019). Furthermore, as described by other investigators, this research shows that recovering from experienced trauma should occur in the context of relationships (Fitzduff, 2016; Gutlove & Thompson, 2004; Mukashema & Mullet, 2010; Summerfield, 2002).
Being able to build and maintain satisfying relationships such as those participants experienced in groups is an essential for a return to normalcy and working with other members of the family and community. Daily stressors need serious attention, because in connection with the psychological effect of the conflict, there is a serious risk that people's mental problems will reoccur if the daily stressors are not addressed. As has been shown for participants in the counselling group, stress can be reduced by improving their coping mechanisms. MHPSS problems have a negative effect on imagination and without imagination people lose hope and energy (van der Kolk, 2014). At the same time, if nothing is done to address people's extremely poor economic situation and repair their social fabric, their coping mechanisms will not suffice – these issues are interrelated. High levels of social fragmentation are related to negative economic productivity trends (Vinck et al., 2007) and due to the mental and physical effects of traumatic experiences, people may have no energy and difficulty planning their lives and activities.
This research indicates that it does not seem possible to live in peaceful coexistence if people's mental health and social relationship problems are not addressed. The MHPSS and PB fields are deeply interconnected. Trust and empathy are the glue for interpersonal connection and social fabric repair. In an insecure environment with conflict and circles of violence, development and psychosocial wellbeing is very difficult, as is the transformation into a peaceful society.
The findings of this study are in line with the statement by Burrell and Barsalou (2015) that people need the capacity to empathise and think about the feelings and beliefs of others for PB. However, this is only possible if one's own emotions and thoughts have been attended to as well – otherwise PB efforts are likely to fail (Fitzduff, 2016). The capacity to empathise with the other and really hear the other's story is an important outcome of group counselling. By telling individual stories of (social) suffering and listening to the stories of the other group members without judgement, the participants regain a certain level of dignity and empathy for the other, which is needed for reconstructing relationships. As Korac (2006) indicates, coming to terms with individual traumatic experiences is significantly linked to the process of group reconciliation.
Feeling better and having improved relationships with other people have allowed the counselling group participants to regain hope and energy. The fact that the groups continued to meet in the economic empowerment group, in which they learn livelihood skills and money management was an essential part of the transformation to living in peaceful coexistence. The economic position of most families has improved, and most participants said that they now can meet their basic needs. This also shows that the participants' feelings of security and confidence have improved. This outcome has had a radiating effect on the groups' family members.
Based on our findings, the first intervention must be the counselling group, because mental and interpersonal relationship problems and a lack of healthy coping skills, all hinder peaceful coexistence and social and economic development. The combination of therapeutic and educational approaches in the counselling is very helpful, because it not only brings people closer together and reconnects them, but also helps them to cope better.
This research shows that conflict management is important for at least two reasons. First, due to the long war in northern Uganda, people have not learned how to solve conflicts in a nonviolent and peaceful way. Second, the way that traditional leaders manage conflict is generally based on old standards, with more emphasis on male rights, for example, and making decisions instead of mediating and coming to consensus. All participants considered CSS as important and although the number of people who have consulted the CSS was not clear, it is growing and increasingly considered as a trustworthy and respectful organisation capable of delivering justice. The CSS way of working also increases people's security, both inside and outside the family since every village has a member in the CSS, who works without pay and is easy for community members to approach. The CSSs are also conducting awareness-raising activities on mental health, several (harmful) practices, peace messages and dispute resolution in their communities. Thus, the risk for a CSS member of becoming overburdened is real and should be monitored very closely.
Limitations
This study had a strong qualitative part, so the observation and self-reporting components relied on interpretation rather than fixed indicators. It is generally understood that the complexity of MHPSS, PB and economic development issues result from the interaction of many factors whose significant correlation is impossible to be statistically determined. The interviews were performed by the TPO Uganda team, thus implying a risk of bias. This problem was minimised by ensuring that the workers did not perform interviews in the regions where they were the implementing workers.
Concluding RemarksPsychological recovery, reconciliation and economic development are intricately interconnected and require an integrated and multisectoral approach due to the complex set of phenomena affecting postconflict societies. For reconciliation and sustainable peace, both the material and economic aspects, as well as the psychosocial and mental health dimensions of people's postconflict experiences, need to be addressed. In other words, “psychosocial services should, therefore, be seen as an integral part of a holistic approach to peacebuilding that addresses individual psychological and community relational needs in addition to physical needs” (Lambourne & Gitau, 2013, p. 24). How the investigated integrated intervention was implemented has shaped the postconflict recovery process.
Based on the study's findings, TPO Uganda's theory of change was effective. Community members who were supported to overcome past traumas and psychosocial distress through psychoeducational (groups) counselling were able to interact in a healthy and productive way with other members. The CSS rejuvenated traditional support structures were able to mediate/resolve disputes peacefully. CSS also sensitised communities to experience peaceful coexistence and tolerance for common GBV drivers. This all helped the participants to regain their agency and dignity, enjoy better social functioning and peacefully coexist, exercise tolerance and live in harmony. The programme exemplifies good practices by linking MHPSS with PB and economic development while strengthening traditional support structures.
Acknowledgements
The authors thank the beneficiaries of the TPO Uganda programme in the Acholi and Lango regions in northern Uganda who participated in this study for their willingness to talk with the researchers about deeply personal topics. The authors thank the interview team, social workers Sarah Adong, Gladys Amony, Alex Onek Komkech, Ceasar Moses Odiya, Aggney Odokonyero and Grant Opiyo for their contributions to the study, and we are also grateful for the technical team; Martha Nabwire (Clinical Psychologist), Margret Aber (Peace Advisor) and David Mugizi (Business Development Officer) as we are for the language editing by Julia Challinor.
Financial support and sponsorship
This evaluation was funded by USAID. The findings, interpretations and conclusions expressed in this report are entirely those of the authors.
Conflicts of interest
There are no conflicts of interest.
1In the safe-place exercises, people imagine a place where they feel safe. The exercise helps them to come to grips with their fear.
References
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