An Introduction 
to the 
Program on 
Mental Health
Director: Mesfin Araya, MD.

m.j.t. trapman, aug '96-sept '97

I. Context.

Armed conflict has had great influence on Ethiopian Society in the past decades; armed conflict not only within Ethiopia, but also within the neighboring countries Somalia and Sudan. The country now bears the burden of caring for 400,000 internally displaced people, mainly as a result of the recent independence of Eritreia, as well as for an estimated 390,000 Refugees, mainly from Sudan and from Somalia, figures still rising every day.
Ethiopia is in a phase of economic reconstruction, and the care for all these people could not have been performed without support from many international donors and relief organizations. Yet, the structure in which the relief has been supplied has had disconcerting side-effects such as relief-dependency, despair and resignation within the communities of displaced and refugees, which in turn has lead to the phenomenon of donor-fatigue.

In the past years it has become clear that Ethiopia is not in the position to offer big solutions: plans for housing projects for instance run up against land shortage and necessary decisions in urbanization policy.  Yet, there is another way to solve this problem: by the individuals themselves, coming up with a multitude of individual solutions, flexibly adapting to those opportunities they themselves perceive

This avenue, however, cannot be followed by large organizations nor be created by general policy. It can only be created by the families within the body of the population of displaced themselves, and we therefore have to cease viewing 'the displaced' as a community or as a single unit: we must allow for the fact that the displaced do not have a common future- in fact the only thing they share is one aspect of their past.

In a recent workshop, organized by CRDA, on the situation of Displaced People in Addis Ababa, it was concluded that piecemeal solutions, and response to solutions from within the communities would have to be stressed in the future. For this, however, it is necessary to consider if it is reasonable to load such responsibi-lity for solutions onto the shoulders of the displaced themselves, given the circumstances they are currently forced to live in.

 The plight of the
Displaced and the Refugees
within Ethiopia.

All people that have been forced to relocate as a result of armed conflict share in some way a past of horror, fear, bereavement and a multitude of losses, material as well as immaterial.
Once fugitives,  they are inevitably caught up in political controversy within which concepts of guilt and innocence become fluid and manipulated, not only by those in control but also by the international relief industry.

Shocked and often traumatized by the events from which they have escaped, weakened by physical hardship, they are stripped of their identity, the base of self respect: to become part of a nameless mass in which no individuality, no origin, no exception can exist.
After armed conflict, huge efforts are made by specialized systems like UNHCR, and countless international NGO's in the field of relief, to meet the need for food, shelter and basic health care. Huge efforts that have created their own logistics, familiar to all who witness these man-made disasters, either through personal experience or through the eye of the media.  Refugee-camps, food-distribution, emergency-care for rows of emaciated women and children, and the burial of countless nameless bodies in immense graves: images that have become the icons of our time.

Yet the very structure of these logistics creates, as we are now beginning to understand, a second ordeal for those who have escaped the inferno. Survivors from the Holocaust and refugees out of many wars in the past decades testify to this ordeal: how the silence, the denial of what happened, the attempts to forget, have incapacitated them, physically disabled them, mentally blocked them against choosing a new future. It is this inability that is widely experienced by desperate relief-workers as indolence or fatalism. And it is this inability, indeed, that is the base for the tragic addiction to relief that emerges in the camps.

Only through the work that has been done in recent years with those who have experienced the horrors of war are we now starting to understand that there is another field in which immediate support is necessary directly after crisis: the field of mental health. Mental injuries, however, are not directly visible to the camera, mental trauma is even often disguised by the escapees themselves, because they have to cope, on a day to day base, with life as it is left to them. But like anybody who has suffered, they have the need to mourn, to go through what has happened time and time again, to be heard, to be able to give meaning to the past and to the future, to reconstruct themselves. These needs, we now come to understand, are as real, as concrete, as the needs for food and shelter, and if not met, they will inevitably result in personal and social disaster.

Mental injuries are manifold in character. The term 'Trauma' has lately become a fashionable means of sweeping all of them together, but there are huge differences between the girl that is hounded by nightmares and flashbacks, the cripple, staring in disbelief at the empty spot where he still feels his legs,  the widow, suddenly responsible for her household, looking into the future with empty eyes, the alcoholic ex-fighter(boy) with an uncomprehended history of rape and murder, and the child that is born in the camps and is growing up, absorbing the burden of the adults around it.
All of them will, after some time, appear to adjust to the rhythm of life in a shelter, to cope somehow. But if they are not allowed in some way to process their grief, their memories, their hatred, these will not disappear, not be forgotten. On the contrary,  they will be buried in their minds and will poison their capacities for readjustment, for a new beginning.
In a healthy community, traditions exist to support individuals to process their feelings - but after armed conflict the community is destroyed, and these functions have to be reconstructed again.

This is the object of the program that we are presenting: to develop a program for intervention in the field of mental health which will allow physical health workers, nurses,  and all others involved in the care for displaced and refugees, to understand, recognize and alleviate the mental health problems that arise after armed conflict,  and to support the management of these problems by the victims themselves.

Anchoring within the existing structure.

This program aims to develop a curriculum within the Addis Ababa University, and to develop a tutorial that conveys practical methods to those already operational in the field. Mental heath care may be, a separate and independent form of care, but the institutions administering this care in general do not have to be separated.
Mental health care will also, very often, have to be an integrated part of other forms of care: influencing, for instance, the organization of relief-efforts, the form of shelter that is offered, the priorities that are made in emergency health care.

A flexible approach; developing a framework for Ethiopia .

Also, this program does not, indeed it can not, offer a standard program, although it is part of an international effort to gain insight and experience from the testimonies of victims all over the world. Because out of all their testimonies, one thing has become absolutely clear: there is no world-wide solution to their plight. Suffering, mourning, death and loss: they are differently defined and borne in each culture. Mental health and mental illness are also different from place to place, from culture to culture. Healing is not only an individual matter, it is in many aspects a social process, for which traditional healers have essential keys to offer.

The program therefore, sets out to develop a specific and Ethiopian curriculum, or even curricula, since it aims eventually to support displaced and refugees from different origins and cultures.

Yet, an international Program.

Yet, as mentioned above, the program is essentially part of an international program to fight the consequences of war, to understand the ways in which armed conflict reaches through generations and emerges time and time again like a fire that lives underground. Not only does the program draw from the experience and testimonies of people all over the world, but in turn it will also give: communities as wide apart as from Cambodia, Nepal, Gaza, Mozambique and Uganda are now sharing experiences through the TPO program that is connecting them.

 A plea for the continuation of Relief, based on New Principles.

Currently some important NGO's have pulled out or are about to pull out from the relief efforts that were offered to the displaced in the past five years. Other important international organizations have redefined their priorities because they felt that their efforts were in vain, or not being given the right framework in which to exist. Yet, a project like the one we will undertake cannot exist for people that are left entirely on their own in shelters which wear out after 5 years of use.
There are however, also some contrary developments: GTZ is starting a reintegration program for displaced funded by the EU, and also the Taskforce within CRDA is searching for new venues.
Within this new framework we would like to participate, and in a joint effort by all concerned bodies to help to start a new program.

Developing the Shelters into a strong base for Departure

The less we concentrate on providing a future for the whole body of displaced people, the more we can concentrate on turning the existing shelters into a strong base for departure. Material as well as non-material provisions will have to be restructured to create the atmosphere of departure in an airport or harbor from which people are leaving on a steady base; the rhythm of good-bye's becoming the heartbeat of the shelter.

To reach this situation,  the current structure of the shelters must be thoroughly changed because, paradoxically, they have become a kind of safe-haven for the displaced, safe from a hostile world outside the shelters.

The center of such a new structure could be the design and construction of a multi-purpose hall by the displaced in or near the shelter.
The design and other aspects of this construction could be the subject of vocational training. The construction itself might be part of a food for work program.
The result would have to offer good office-space for the committees and for those heads of families that are involved in concrete plans for their future. It would also have to provide space for meetings and for festive rituals connected to important steps in the process of leaving.
Rather than stabilizing the existing shelters, these constructions should be designed to serve the local communities of Addis Ababa when, or maybe even before, all the displaced have left.

Activities and support might be centered in the first place (and specifically counter to western help-reflexes) on the strongest in the community: those who might be the first ready to leave.
This is not to say that the weakest should be forgotten, but even to them, the activities of the strongest could form a beacon, a focal point at which to aim, an inspiration to regain hope and therefore the strength to come out of their misery. This mental step might exactly be what even the weakest need in order to regain physical force from the relief they receive.

Activities would also center on, as well as depart from the ideas and activities of the displaced themselves.
Here the results of the TPO-program will first become visible.
Personal and group counseling result in the process of reliving of past ordeals. Forms will be developed to express these memories and the feelings they invoke: creations in the field of painting and music may be expected in the Ethiopian culture,  reunions that might feel alike the mourning rituals that are well known. Story-tellers, readily available within the communities of the displaced, may become central in new forms of collective processing of traumas and symbolic activities that will give new meaning to past, present and future.

All forms of relief-work can develop forms to fit within this structure of  rehabilitation; some of the clinics for example have already been concentrating on health education, rather then simply treating illnesses as they present themselves.
In the same way, each element of classic relief work can be turned into a response to action from the side of the displaced, rather than originate from the help-instinct that is the basis of western humanitarian action.

Rehabilitation Program: a Dangerous Contradiction in Terms

Just as we should remember the Ethiopian observation that religiously induced generosity often creates the beggars, rather than helps them to become self-supporting, we should realize that there can be no such thing as "rehabilitating somebody" from the outside: rehabilitation can only be a process from within the displaced themselves. We do not mean that activity from the outside is impossible; on the contrary, if that were the case, we would not be involved ourselves. We need, however, to stress the fact that any program which wants to be successful, should carefully look for initiatives from within, in contrast to inducing or preconstructing general ideas about the future.

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