Searching for Normal in the Wake of the Liberian War. Sharon Alane Abramowitz

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СКАЧАТЬ decision makers, to Liberian and expatriate psychosocial and mental health workers, to Liberian program beneficiaries, and to Liberians who were excluded from psychosocial interventions (Marcus 1995). I also sought to examine mental health and psychosocial interventions cross-sectionally by looking at the experience of humanitarian/local interactions around psychosocial intervention at the point of their convergence in daily life.

      The goal of this chapter is to contextualize the mental health and psychosocial interventions described in the remainder of this book in the prewar, wartime, and postconflict histories of Liberian mental health, trauma-healing, and psychosocial rehabilitation. Therefore, the primary task of this chapter is to write a “history of the present” for Liberian mental health in order to provide a framework for understanding the postconflict paradigm that emerged after 2003 by following the discontinuities, conflicts, and uncertain progress toward the creation of a Liberian national mental health policy, a WHO priority for national mental health systems. As the processes of humanitarian coordination, prioritization, and distribution of resources unfolded, they revealed the uncertainties and ambiguities of the postconflict moment. These processes were rooted in a dynamic of global-local engagement that was fractious, complicated, and bidirectional, and always filled with a sense of unknown ends (see Chapter 4).

      In the data collected for this chapter, nearly all of the historical material from the era before 2004 is the result of archival work, retrospective interviews, and publicly available NGO documentation (also known as the gray literature). In contrast, nearly all of the material post-2005 is based on participant observation, key informant interviews, and a careful process of cross-validating informants’ accounts with NGO, local informant, documentary, and international sources. This process of tracking down the “living history” of humanitarian implementation was a side pursuit to my multisited ethnographic fieldwork, in which I tracked mental health, psychosocial, and trauma-healing interventions in clinics, hospitals, NGO offices, government ministries, shantytowns, rural villages, and UN bases. My research transected four counties in Liberia (Montserrado, Bong, Lofa, and Nimba), and in them, I tracked patients with mental illness from clinics to hospitals; studied the financial and physical flows of aid from the capital to the country’s “most-affected areas” (Nimba, Bong, and Lofa counties); and followed the movement of mental health workers through their various assignments. I tracked the movement of policy documents through institutional hands, the gradual expansion of safe space, the availability of over-the-counter psychoactive medications from local markets to urban ghettos, and the usage of psychiatric medications inside and outside of mental health facilities. In my characterization of “the psychosocial” as a nonhuman actor that has agency, yields symbolic, interactional, and material effects, and creates logics of momentum, expertise, and resources in the decentralized, deinstitutionalized, and heterogeneous context of Liberia’s postwar humanitarian world, I owe a considerable debt to the work of Bruno Latour, and to actor-network theorists (Callon 1991; Callon and Law 1997; Latour 2005; Law 1992; Law and Hussard 1999).

      My movement through Liberian mental health, trauma-healing, and psychosocial work has been shaped by intuition, by access, and by my understanding of the concept of “the interventionscape” (Abramowitz and Benton 2005) as a nexus of complex, chaotic, deterritorialized humanitarian institutional interactions and global processes (see also Appadurai 1996) that constitute the culturally distinctive domain of “networked interaction” (Hall et al. 2001; see also Duffield 2001 on global governance) we have come to think of as humanitarian intervention. Across the interventionscape, flows of resources, personnel, bureaucratic protocols, administrative practices, financial mechanisms, and ethical guidelines shape the space of mental health, trauma-healing, and psychosocial intervention in the unique Liberian postconflict landscape and give it its meaning, form, and impact. I entered the theater of mental health intervention through interviews or fieldwork visits with prominent agencies in Liberian mental health like the Center for Victims of Torture ([CVT] a U.S.-based NGO), Cap Anamur (a German emergency medical NGO developed on the model of Médecins Sans Frontières [MSF]), and Médecins du Monde ([MDM] a French medical NGO), through Liberian institutions like the Ministry of Health and Social Welfare (MOHSW) and the Mother Patern College of Nursing and Social Work, through expatriate psychiatrists, consultants, and aid workers, and through Liberian psychiatrists, psychologists, mental health social workers, psychiatric nurses, gender-based violence advocates, trauma healers, and psychosocial workers.

Figure 1. Katherine Mills Hospital. Photo by author.

       1994–2003: Postconflict Mental Health

      During Liberia’s prewar existence, the country’s mental health infrastructure resembled that of many other sub-Saharan African countries. Formal mental health care in the nation’s capital often meant psychiatric hospitalization, while traditional mental health care in urban and rural areas often meant herbalists, witchcraft or sorcery trials, traditional medicine treatments, or fairly primitive methods of physical containment, using chains, ropes, or blocks of wood as anchors or foottraps. There was one center of modern psychiatric care in the national capital, the large, modern Katherine Mills Rehabilitation Institute in Monrovia, which was part of the Monrovia-based John F. Kennedy (JFK) Hospital system.¹ There was also a small, private, in-patient psychiatric hospital called Grant Hospital, owned and managed by Dr. Edward S. Grant. The hospital had a forty-bed capacity and was adequately furnished in a limited sense; it had dormitory rooms, a kitchen, outdoor and indoor recreational areas, and a medical dispensary.

      Between 1994 and 1997, as Liberia’s health infrastructure crumbled under the weight of civil war, the international community made its first foray into managing trauma in Liberia and into surrounding refugee sites in Sierra Leone, Côte d’Ivoire, Ghana, and Guinea. These early psychosocial interventions, then conceived of as trauma healing, ex-combatant demobilization, and psychosocial stabilization, were seen as novel, legitimate, and necessary. In Liberia, the WHO and the Lutheran World Federation/World Service (LWF/WS) were leaders in trauma management. The WHO provided short-term support for technical guidance, hired consultants to run trauma-healing training sessions, and oversaw pilot projects in ex-combatant rehabilitation. In contrast, the LWF/WS Trauma Healing Program built a large, community-based trauma-counseling program that operated continuously during the war, and developed a positive reputation across Liberia. Neither set of interventions were monitored or evaluated, and their efficacy remains unknown.

      Figure 2. Entry, Katherine Mills Hospital. Photo by author.

Figure 3. Main gate, E. S. Grant Hospital. Photo by author.

      Both the WHO and the LWF/WS oriented their psychosocial education to “scale,” targeting communities and groups rather than individual mental health counseling or treatment. Both also espoused a “training-of-trainers” (TOT) model meant to promote the sustainable dissemination of psychosocial knowledge. In the TOT model, short-term topical training sessions were offered to Liberian participants, who were then encouraged to go into their communities as local trainers, or health educators, and share their findings about trauma and mental health. But the LWF/WS’s long-term presence in Liberia and its rapid shift from an expatriate staff to a local Liberian staff seemed to have the effect of “indigenizing” the program, giving it a quality of local ownership that WHO initiatives seemed to lack. The LWF/WS program repeated training sessions in communities, had a long-term relationship with communities, and often spent the night in those communities. In the quiet night hours, after the official end of the training day, trainers would provide individual counseling to community residents. They also ran “after-hours” women’s encounter sessions where women recounted experiences of rape, or of sending family members to war. Eventually the LWF/WS shifted its training materials’ emphasis on PTSD theory and СКАЧАТЬ