Relief Groups can Create Unintended Chaos

by John R. van Eenwyk, April 3, 2005
Sri Lankans knew something was amiss on Dec. 26 when water started appearing in their houses. When they went outside to see what was happening, they saw a wall of water approaching that -- depending on how far inland they were -- contained everything from concrete slabs to cars to people. On its way in, the third wave smashed everything in its path. On its way out, it undermined everything that was left. That was the first tsunami.

The second appeared shortly after. Like its predecessor it seemed fairly benign at first. Tents, food and medical care were its primary components. But then, a much larger wave appeared. While this one also contained cars and people, concrete slabs were noticeably missing. No one wants to think what the third wave will bring.

Fortunately, a third wave has not yet appeared. A week ago, people weren't so sure. Warnings that an 8.7 earthquake off the coast of Sumatra could possibly generate another tsunami generated frantic scrambling to higher ground. Following the all-clear, however, a euphoria of relief replaced the prior panic.

As you have perhaps guessed, the first tsunami was of natural origin. The second was of human origin. The first was predominantly water. The second is predominantly NGOs (non-governmental organizations). Which will prove to be the more destructive in the long run is yet to be determined. All we know at the moment is that they bear a strange resemblance to one another.

Having recently returned from four weeks of relief work in Sri Lanka, I must admit that I was part of the second tsunami. Together with relief workers from around the globe, we make up a truly formidable wave that is leaving as much of a mark on Sri Lanka as did the first tsunami. Hopefully, ours will be much more salutary.

The first thing one notices about the NGOs is that they are far wealthier than the Sri Lankans they serve. In a land where bicycles are an improvement on walking and motor scooters are a luxury, the new, gleaming, enormous 4X4s in which the NGOs arrive broadcast wealth and privilege before their occupants disembark. Those Sri Lankans who are confined to refugee camps know that when these vehicles arrive, well meaning and sincere relief workers will shortly be scurrying about telling them what to do. Those who are not either watch from afar or figure out ways to cash in on the influx.

Either way, the arrival of the NGOs inevitably generates expectations that are impossible to fulfill. In some cases, the expectations are out of line. In others, the NGOs are. Gaps between expectation and actuality usually increase the further up the decision-making hierarchy one goes.

For example, the head of one European NGO lamented that the decision-makers, who inhabit comfortable offices far away in the home country, had mandated that only food and shelter constitute relief. Anything else is not funded. Thus, providing boats and nets to fishermen who have lost everything is not permitted. Giving them food and tents, however, is.

I asked if they'd heard the saying: "give a man a fish and he eats today; teach him to fish and he eats for a lifetime." She rolled her eyes. Her choices are clear: Either do what she knows is needed most in any particular area and defy the home office, or follow the guidelines and stay out of trouble. How strange! Those closest to a situation seem rarely allowed to make decisions.

My role in relief work, however, is not to provide food and shelter, let alone nets and boats. I am a psychologist. My job is to train counselors. Fortunately, I have two things going for me. Firstly, as this is my fifth visit to Sri Lanka, I know most of the people with whom I am working. Secondly, as I am the founder and clinical director of the NGO that has sent me here, I am both the relief worker and the decision maker.

Unfortunately, my approach to relief work seems to unsettle potential funders. Beginning with my first experience of this sort (Gaza, 1991), I have realized that the people I am training know far more about the situations they address than do I. Thus, my "training" is actually collaboration -- brainstorming, if you will. I share what I know and they share what they know and together we come up with new ideas for the current situation.

Funders understandably like to know what they are buying with their money. I can't say what the product will be until we develop it. Further complicating things is that our program also brings practitioners from war zones and other locations that are experiencing "complex emergencies" to Olympia for three months of collaboration (read: "training"). While a considerable amount of funding exists to treat refugees living in the United States, bringing practitioners from other countries doesn't qualify.

So, we operate on a shoestring. No gleaming 4X4s for us; no luxury hotels; no business class on those 14-hour flights. No fancy uniforms. No video crew to record our efforts for the media back home.

Which gives us a lot of what is known in this country as "street cred." People tend to trust more easily those who eat, sleep and suffer with them. We don't look better than they do. And it certainly doesn't hurt that we come from a developed country with all of its promises of highly sophisticated techniques that can cure any ill.

Which makes us a lot like Wizards of Oz. People look to us to give them what they believe they don't have (counseling skills, in our case). Our job is to gently reveal ourselves as the "man behind the curtain." Then, we help them to see that what they seek from us they already possess. Like the scarecrow, they already have brains. We give them diplomas. We don't indoctrinate. We empower.

This is not difficult, for particularly in the case of trauma treatment, people have been doing it for thousands of years. Trauma treatment did not originate with the invention of counseling. So, we ask what has worked in the past? How can it be adapted to the present? How is counseling dynamically similar to religion, culture and custom? What kinds of synergy evolve from dialogues between the two?

During one five-day workshop, my colleague, Keylee Marineau, and I asked a group of counselors to divide into groups of four and to role-play a particular situation. Each sub-group reported back via a fully scripted theater piece. Drama was obviously their most effective training tool. At that moment, counseling and culture coalesced.

This kind of horizontal approach to learning is what NGOs do best. Those actually carrying out the mission usually collaborate with those they are serving. Nevertheless, the funders and those in the home office often have a different attitude. However well intentioned, their efforts inevitably bear the stamp of the "haves" serving the "have-nots," the superiors caring for the inferiors, the blessed ministering to the cursed.

This attitude often attends those who presume to counsel people in another culture. For example, Sri Lanka has been invaded by "traumatologists," who arrive armed with techniques guaranteed to stop all trauma, most of which deepen and complicate it. Sri Lankans cannot wait for them to leave.

They feel the same about most of the NGOs. As was the case during the 25-year civil war, NGOs generate an economy all their own. They rent apartments at five times what locals can pay, thereby displacing the very people they came to help. They eat up the food. They hire drivers, cooks, housekeepers and translators. While there, they use up the resources. When they leave, the economy collapses.

Which makes relief work inordinately complex, dishearteningly fragile and frustratingly difficult. It's a pact with the devil. Those who recognize this have much more realistic expectations of what they can achieve and how people can respond. Those who do not are forced to invent stories of success. Sham and scam in a complicated dance.

Through it all, a lot of good work is accomplished. Many good people work together in ways that the public never sees. Unlike the tsunami, they don't undermine the foundations of the culture. The relationships they build generate a momentum that carries everyone through present and future challenges. They make the waste and ineffectiveness that characterizes relief work acceptable.

They also create a worldwide community of people who believe that equality, tolerance, and open hearts and minds are the future of the human race. They stand in stark contrast to those who feel that violence, power or imposing one's ideas on others is the way to salvation. They serve as an example for the rest of us to follow.

And so, mindful of the perils of the journey, the relief effort trundles onward. However exhausted and underpaid, we love the work. It sure would be nice to be able to afford business class, though. We could pester the arms dealers.

The Rev. John R. Van Eenwyk is an Episcopal priest, clinical psychologist and founder and clinical director of the International Trauma Treatment Program.

Seattle Post-Intelligencer

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Bread and Shelter, Yes. Psychiatrists, No.

by Sally Satel, M.D., March 29, 2005

Days after the tsunami struck South Asia, American mental health workers flew to Sri Lanka to offer counseling services to grief-stricken victims.

"Psychological scarring needs to be dealt with as quickly as possible," one psychologist told The Washington Post in January. "The longer we wait, the more danger."

Sri Lankan health officials saw things slightly differently.  They discouraged aid agencies that offered to send counselors to their country.

"'We believe the most important thing is to strengthen local coping mechanisms rather than imposing counseling," Dr. Athula Sumathipala, chief of the psychosocial desk at the Sri Lankan government's Center for National Operations, told The New York Times the same month.

I found the contrast between the two men particularly striking because I had recently gone to Rome to attend an international conference on trauma.  The conference, titled "Project One Billion," was organized by Dr. Richard Mollica, a psychiatrist at Harvard, under the auspices of the World Bank, the World Health Organization, and humanitarian nonprofit organizations. The United States also provided support.

"One billion" signified the number of people worldwide, roughly one in six, suffering the psychological consequences of war, torture and terrorism.  And though these people suffered human-caused horror rather than natural disaster, the question still applies: can outsiders bearing therapy provide meaningful help in times of crisis?

One thing is clear.  Even before strife ripped these societies apart, many of them had pitiful mental health systems.  According to the W.H.O., most developing countries have fewer than 1 psychiatrist per 100,000 people; in rural areas, the gap is even larger.  The entire country of Rwanda has only one psychiatrist. (The United States has about 14 psychiatrists per every 100,000 people; England has about 4 per 100,000.)

Experts at the conference emphasized four undertreated mental conditions: psychoses (mainly schizophrenia), major depression, drug and alcohol abuse, and epilepsy (a neurological disorder often treated by psychiatrists).  They noted that depression and drug and alcohol abuse increased in the aftermath of violence and destabilization. When they spoke of post-traumatic stress disorder, on the other hand, it was more as a nod to the organizing theme of the meeting.

True, suffering was abundant - "We cannot dry our tears," said one African representative - but psychiatry was not the obvious answer.

It would not be the first time that psychological aid was regarded by non-Western recipients as a kind gesture but a bad fit.  For the last 15 years or so, humanitarian workers have been exporting the concept of post-traumatic stress disorder and trauma counseling around the globe.

They have rushed in to impose Western "debriefing" - a group therapy technique intended to get victims to express their feelings about a horrific event and to relive it as vividly as they can - without regard to the needs of the victims, their natural healing systems or their very conception of what mental illness might be.

Indeed, as literature from CARE International put it during the Balkan conflict: "Almost everyone in Kosovo will consider her- or himself traumatized."

But is this true?

Several years ago, a resettlement project run by the United States government for Albanian Kosovars at Fort Dix, N.J., was staffed with mental health specialists prepared to treat high rates of post-traumatic stress disorder among the refugees.  Those expectations were not met, observed Elzbieta Gozdziak, an anthropologist at Georgetown University who was part of the team.

"Only 7 of the 3,000 refugees were found to need psychiatric care," Dr. Gozdziak said.

Indeed, many program evaluations reveal that actual use of specialized psychological help is typically low.

Kenneth Miller, a psychologist in the Bosnian Mental Health Program in Chicago, saw much suffering among his clients - they had been placed in concentration camps before migrating to the United States - yet the most successful feature of his program was not therapy, which most clients rejected anyway. It was practical help like education and job training.

Dr. Elie Karam, a psychiatrist at the Institute for Development, Research and Applied Care in Beirut, who attended Project One Billion, similarly concluded that post-traumatic stress disorder was not a major issue.

"What we found was that the violence served as a catalyst for the destabilizing effects of pre-existing problems in people's lives such as poverty, marital discord, physical illness," Dr. Karam said.

Project One Billion reflected this philosophy. Debriefing, Dr. Mollica stated, has been discredited in clinical trials.

In its place, he strongly urged that Western mental health workers collaborate with indigenous healers.  The W.H.O. now instructs aid workers to "listen, convey compassion, assure basic physical needs, not force talking, and provide or mobilize company preferably from family or significant others."

Notably, mental health advisers acknowledge that local economic and social recovery is a prerequisite for improved psychology, not a consequence of it.  As Dr. Mollica put it, "the best antidepressant is a job."

The very same week that Project One Billion took place, a "Dare to Act" conference was held in Baltimore.  Supported by federal tax dollars, the conference promoted an inward-looking "trauma paradigm," holding that childhood and adult traumatic experiences lie at the root of most psychopathology.

A colleague of mine who works with Bosnians, Hmong and Somali refugees told me he was asked by organizers of the conference to provide a refugee woman to talk about "her trauma" at the conference.

He asked around but couldn't find one. "They don't want to think of themselves as victims," he said.

Sally Satel is a psychiatrist and resident scholar at the American Enterprise Institute and a co-author of a new book, "One Nation Under Therapy: How the Helping Culture Is Eroding Self-Reliance."

New York Times

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Posted April 5, 2005