The possible link between MHPSS and peacebuilding
An analysis of the Classroom Based Intervention and its contribution to cultural peace, human security and ultimately sustainable peace in Nepal
This thesis is submitted for obtaining the Joint Master’s Degree in International Humanitarian Action.
By submitting the thesis, the author certifies that the text is from his own hand, does not include the work of someone else unless clearly indicated, and that the thesis has been produced in accordance with proper academic practices.
Author: Kyra Cornelissen
Year of Conclusion: February 2014
First Supervisor: Relinde Reiffers, external supervisor
Second Supervisor: Joost Herman, Rijksuniversiteit Groningen
Abstract
Within the field of Mental Health and Psychosocial Support (MHPSS) its possible link to peacebuilding is topic of current concern. The extent to which MHPSS has potential to positively promote psychological- and psychosocial aspects that contribute to social transformation requires further investigation. In this research the possible contribution of MHPSS to peacebuilding and its implications for the field of humanitarian assistance is investigated through the analysis of the Classroom Based Intervention (CBI) in Nepal. This research consisted of the analysis of the evaluation of the CBI and a literary research, the conceptual framework used for the analysis of the results is based on Galtung’s theory of sustainable peace and the human security approach. The results presented in this research indicate that the CBI, through its contribution to psychosocial well-being and social behavioural change of children and adolescents promotes mutual trust, social relations, concern for others and community building. The CBI therefore preserves and promotes health and several aspects of social security. The CBI has potential, and may be necessary even, to promote cultural peace in the direct areas of its implementation. The extent to which the CBI can contribute to sustainable peace is dependent on the extent to which its psychosocial support can be provided simultaneously with other human security needs. If MHPSS is provided simultaneously with programs that provide in direct and structural needs, MHPSS can, through its positive impact on several human security needs and cultural peace make a valuable contribution to sustainable peacebuilding. Children and young people, due to their key position for societal change, can play a significant part within this regard. It is highly advisable for the field of MHPSS to conduct future empirical and clinical research to investigate the effect of their programs on attitudinal change and other indicators of social transformation. This eventually contributes to the accumulation of evidence-based knowledge of the contribution of MHPSS to social transformation, and can therefore both establish en reinforce this contribution.
Table of Content
Introduction...5
Problem statement...6
Implications for children...7
Aim and research objective...9
Classroom Based Intervention...11
Relevance...12
Methodology...13
Limitations...13
Chapter 2. Theoretical framework...14
2.1 MHPSS...14
2.2 Sustainable peace...15
2.3 Human Security...17
2.4 Reconciliation...20
Chapter 3. Context of implementation...22
3.1 Setting...22
3.2 Civil war...22
3.3 Mental health and psychosocial well-being...23
3.4 Children...25
3.5 Peace and security in Nepal...26
Chapter 4. Treatment indicators...28
4.1 Evaluation of the CBI...28
4.2 Psychiatric symptom reduction...29
4.3 Reduction of psychosocial and behaviour problems...30
4.4 Promotion of prosocial behaviour...32
4.5 Increase of a sense of hope...36
4.5 Conclusion...38
Chapter 5. Cultural peacebuilding in Nepal...41
5.1 Children and young people in relation to peacebuilding...41
5.2 Young people in Nepal...42
5.3 Contribution CBI to cultural peace...43
5.4 Conclusion...45
Chapter 6. MHPSS and human security...45
6.1 Contribution MHPSS to human security...45
6.2 Contribution human security to MHPSS...48
6.3 Importance MHPSS and human security to peacebuilding...49
6.4 Conclusion...49
Chapter 7. CBI and sustainable peace...51
7.1 Impact of the CBI on human security...51
7.2 Contribution of the CBI to sustainable peace...53
7.3 conclusion...55
Chapter 8. General conclusion...56
Implications for the field...57
limitations...58
References...59
List of abbreviations...68
ANNEXES...69
Annex 1. Description of the Multilayer Psychosocial Care Package for Children in Areas of Conflict69 Annex 2. Intervention pyramid...71
Annex 3. Galtung’s triangle of conflict, violence and peace...72
Annex 4. Model of youth programming in post-conflict settings...73
Introduction
Reaching sustainable peace after intrastate conflict is a vast and long-term challenge in every post-conflict society (Eastmond, 2010). People affected by violent conflict are often exposed to distressing and traumatic events such as violence, executions, torture, sexual abuse and other harassing acts, loss of loved ones and forced recruitment. Moreover, daily stressors that encompass the post-conflict situation such as poverty, forced replacement to camps, starvation or the outbreak of diseases mediate the levels of psychosocial distress and mental disorders (Jordans et al, 2012). These traumatic events are all determinants for an elevation of psychosocial distress and psychological problems. Post-Traumatic Stress Disorder (PTSD)1, other anxiety disorders2 and depression3 are the mental disorders most commonly associated with societies affected by violent conflict (Jordans et al, 2012). Other psychosocial problems such as the experience of intense negative emotions as a consequence of the conflict, an increase in aggressive and violent behaviour and a lack of community trust are also common.
These mental disorders and psychosocial problems have a negative impact on the well-being, dignity and self-empowerment of those affected by violent conflict (Wessells, 1998).
A sub-group that requires special attention with regard to mental health and psychosocial problems are children and adolescents (IASC, 2007). The impact of violent conflict on the psychological well-being of children and adolescents requires significant attention in the public health agenda (Ventevogel et al, 2013). Children and adolescents affected by violence and other war-related problems are more prone to experiencing psychosocial and psychological problems than those who have not been affected. Mental disorders such as PTSD, other anxiety disorders and depression are common among children affected by conflict. The consequences of war also result in psychosocial problems, such as an increase of aggressive or violent behaviour, and social withdrawal (Jordans et al, 2010a). Children affected by violent conflict are therefore in need of Mental Health and Psychosocial Support (MHPSS). The promotion of these kinds of activities deserves priority within the field of humanitarian assistance. The providence of MHPSS is not only important to promote and preserve the mental health and well-being of the individual. Social transformation must take
1 Post-Traumatic Stress Disorder (PTSD) is a mental disorder marked by psychiatric symptoms after, and as a consequence of the exposure to or witnessing a traumatic life event. The person moves back and forth between reliving the event which is accompanied by intense fear and negative emotions, and the avoidance of these emotions by avoiding all triggers to the traumatic event. Other symptoms are increased aggression and sleep deprivation (Sadock & Sadock, 2007).
2 Anxiety disorders is collective term for a family of, however distinct mental disorders , all marked by intense fear for objects, situations or life in general (ibid.)
3 Depression is a mental disorder marked by a pervasive negative feeling that is experienced internally and influences a person’s behaviour and perception of the world. Other symptoms are a change in appetite, sleep and activity, feelings of guilt, decision making problems and thoughts of death or suicide (ibid.)
place in order to reach a level of reconciliation and deep conflict transformation (Bracken &
Petty, in Ramsbotham, Woodhouse & Miall, 2011).When left untreated, psychosocial and psychological problems can be a threat to development and to the process of peacebuilding (IASC, 2007). This is especially true for children: children are of significant importance for the creation of a positive future. Ultimately children are the basis for this future, for a peace generation. If one wants to achieve long-term change, one must start with the youngest generations (Verloop, 2006).
The foregoing implies that the providence of MHPSS as part of humanitarian assistance and development can contribute, and may be necessary even, to promote sustainable peace. There is however bare scientific evidence of the exact link between MHPSS and peacebuilding. The potential role of children within this role likewise requires further investigation. This thesis will address the providence of MHPSS in post-conflict societies, and its possible contribution to forms of social transformation such as reconciliation and its ultimate contribution to sustainable peace.
Problem statement
One may wonder why the promotion of mental health and psychosocial well-being is so essential to social transformation processes. As mentioned earlier, the consequences of mental health and psychosocial problems do not only negatively affect the individual. There is a connection between mental health and attitudes towards reconciliation (Mukashema & Mullet, 2010). Mental disorders and psychosocial problems resulting from exposure to violent conflict can contribute to a negative and demonising attitude towards the out-group (enemy), vengeance and hostility among youths (Lavi & Solomon, 2005). A study conducted among Rwandan people affected by the Rwandan genocide by Pham, Weinstein & Longman (2004) was the first one to find a relationship between exposure to trauma and symptoms of PTSD and openness to reconciliation, as well as belief in alternative methods to resolve conflict issues. Respondents who met the criteria of PTSD showed the highest reluctance to support reconciliation initiatives. The same connection is found when looking at former child soldiers.
Bayer, Klasen & Adam (2007) found a correlation between the level of PTSD symptoms of former Ugandan and Congolese child soldiers and the willingness to reconcile with their former enemies. Higher levels of PTSD symptoms were also associated with more feelings of revenge. Openness to reconciliation and feelings of revenge among children who met the clinical diagnose of PTSD differed significantly with those who did not meet the clinical
diagnose. Additionally, the nature of the traumatic and distressing experiences encountered appears to have an influence on the openness to reconciliation and feelings of revenge as well.
Children who experienced threat of dead or serious harm showed significantly lower openness to reconciliation and a significant higher level of feelings of revenge (ibid.) In a study conducted by Vinck et al. (2007) those respondents who showed signs of PTSD and depression were less open to nonviolent means of achieving peace in comparison to those who did not show signs of psychological distress4. It therefore appears that the level of exposure to traumatic events is associated with attitudes towards peacebuilding (ibid.) These different studies all indicate a possible effect of mental disorders on attitudes5 and social behaviour on social transformation. None of these authors however provide an explanation or hypothesis for this apparent relation. It likewise remains unclear what aspects of mental health and psychosocial well-being within a population lead to reconciliation and the capability to put aside negative attitudes and behaviour towards the other (Schauer & Schauer, 2010).
Currently much is still unknown about the exact link between MHPSS and processes of social transformation (Brandon & Hamber, 2008; Ventevogel, 2013). One could argue that through the treatment and prevention of psychological problems and psychosocial distress, one can promote attitudinal and behavioural change, and ultimately contribute to the promotion of cultural peacebuilding, albeit at a micro-level.
Implications for children
Though the exact link between MHPSS and peacebuilding requires investigation, the implications for children in areas of conflict can be vast. The prevalence of the development of psychological problems among children affected by war varies from 24, 1% for depression, 37, 6% for anxiety and 20% for PTSD (Luitel et al, 2012). Symptoms of PTSD and clinical depression are related to increased levels of aggression in children. Moreover, children who are struggling with PTSD symptoms can perceive acts of revenge as a rightful approach to repair their personal integrity and to overcome their traumatic experience (Schauer &
Schauer, 2010). Based on this one can conclude that suffering from psychological distress such as PTSD and depression symptoms have a negative impact on attitudes towards
4 Psychological distress is defined as the display of intense emotional and cognitive reactions that emerge and persist as a consequence of stressful life-events. Psychological distress is distinctive to mental illness in that these emotional and cognitive reactions are normal human reactions to abnormal circumstances, and will subside over time when the stressor has disappeared or as people adapt to these circumstances (Horwitz, 2007).
5 Attitudes are hereby defined as negative, stereotyping and dehumanising attitudes towards the out-group, and the reconciliation process.
reconciliation and the use of non-violence against others. Not only children with psychological problems display these negative attitudes and behaviour though. Many of the children affected by violent conflict suffer from psychological distress such as flashbacks, nightmares, social isolation, feelings of depression and loss of hope and perspectives for the future. It may also lead to several psychosocial problems, such as a lack of moral development, increased aggression, and the changing of attitudes and beliefs (Cairns in Wessells, 1998). Furthermore, growing up in violent areas makes children more vulnerable to forces that instigate violence (Schauer & Schauer, 2010). These mental health and psychosocial problems can persist a long time after violent conflict has ended, and are detrimental for children to obtain the best from their education as well as to contribute to post- conflict peacebuilding (Wessells, 1998).
Children may not only be directly affected by violent conflict themselves to experience the negative consequences. Exposure to trauma and psychological problems as a consequence can wreck the social fabric for decades. Social dysfunction is a consistent consequence of violent conflict. Affected parents can leave a psycho-physiological imprint on their children, even their grandchildren (Schauer & Schauer, 2010). This can contribute to dysfunction at the family level, and is often related to an increase in domestic violence. These dysfunctions can be strong facilitators for the continuance of the cycle of violence. Due to the prolonged exposure to violence, children are often habituated to violent means; the use of violence has become normal to daily life and social culture (Wessells, 2005). Trans-generational violence is also common in post-conflict societies. People affected by violent conflict often pass their (collective) trauma, grief and grievances on to their children, and eventually to future generations, which can lead to vengeance (ibid.) This is thought to be an important reason for the high percentage of post-conflict societies that relapse back into conflict (Collier &
Hoefler, 2006). The apparent relation between mental disorders and psychosocial problems among children and their negative attitudes, social behaviour and risk for trans-generational violence indicates that the relatively high prevalence of psychological and psychosocial problems among children affected by conflict can impair sustainable peace. The promotion of mental health and psychosocial well-being through the providence of MHPSS has therefore the potential, and may even be necessary, to promote psychological well-being and reduce these negative attitudes and behaviour. Because if mental disorders and psychosocial problems are not addressed, the breaking of ongoing cycles of violence and engaging in effective post-conflict reconstruction becomes even more challenging (ibid.) Intervention is
therefore of major importance, or as stated by Wessells: the well-being of children is inseparable from peacebuilding.
Although there appears to be a multidimensional relation between violent conflict, psychological problems, the continuance of the cycle of violence and a lack of sustainable peace, this has of yet not been investigated (Schauer & Schauer, 2010).What does this apparent relationship between MHPSS and the process of peacebuilding mean in practice?
And what is the position of children within this process? In other words, if the providence of MHPSS does indeed have the potential to contribute to processes of social change, how is this operationalised in the humanitarian field? In addition, the empirical evidence presented in the previous paragraph mostly focused on the link between mental health and peacebuilding, though it appears that psychosocial problems can also have a negative effect on attitudes and social behaviour. The providence of MHPSS may then have far more potential to contribute to peace than only the prevention and treatment of trauma-related mental disorders such as PTSD, other anxiety disorders and depression. It would be of much interest to identify possible other psychosocial well-being aspects such as social behaviour that can be changed through the providence of psychosocial support, and if so, what these changes might imply for social transformation.
Aim and research objective
In order to investigate and explore the issues addressed in the previous paragraph, this research aims to analyse a case study: an MHPSS program for children, implemented in an area affected by violent conflict. The effectiveness of this intervention on social transformation and ultimate sustainable peace is determined on the basis of the theory of sustainable peace by Galtung (1975) and the human security approach.
The first aim of this research is to analyse the treatment outcome of this intervention and to which extent these outcome variables potentially contribution to attitudinal and behavioural change. A second aim is then to investigate how the children who participated in this intervention can contribute to the process of cultural peace in a particular post-conflict area.
The third aim of this research is to explore the extent to which MHPSS and human security are interrelated, and the extent to which a specific program entailing MHPSS can contribute to the protection of the human security of the respondents and their communities. The fourth aim is then to determine the possible contribution of the intervention to sustainable peace in the
areas of its implementation. The answers to these questions will tell us something about the relation between MHPSS and peacebuilding, and its implications for the humanitarian field.
Due to the apparent higher levels of success of a multilayered intervention technique, integrated in general healthcare facilities or other institutions (IASC, 2007; Luitel et al, 2012) the focus of interest would be an intervention that adheres to these rules. The intervention of choice would therefore be ‘a state of the art’ intervention. Another point of selection is the target population: in order to explore the possible contribution of both mental health and psychosocial support, the intervention must address both. An MHPSS intervention that meets all these requirements is the Classroom Based Intervention (CBI), a secondary prevention intervention approach that is part of the ‘Multilayer Psychosocial Care Package for Children in Areas of Conflict’, designed by Healthnet TPO. Healthnet TPO is a Dutch NGO based in Amsterdam (the Netherlands), that specialises in the providence of both healthcare and MHPSS in conflict and disaster settings. Beside the providence of humanitarian assistance and development support, Healthnet TPO is an organisation with a strong focus on research and development of best practice within the field of humanitarian assistance. One of the areas where Healthnet TPO has been active is Nepal. In 2005 the local office in Nepal became an independent organisation, TPO Nepal. TPO Nepal provides MHPSS to children and families in conflict affected and other vulnerable communities within Nepal6. Since 2004 Healthnet TPO has been working on the development of a community-based intervention package that provides a framework of psychosocial care for children affected by violent conflict (Healthnet TPO, 2013). The content and usage of this package is described in detail on the website of the organisation7, and one can easily get access to detailed descriptions of the different intervention layers as part of this package. The description contains information about the theoretic foundation, the stepwise description of the different intervention layers, clinical and diagnostic screening instruments and results of research into its effects (ibid.) For the sake of the brevity of this chapter, the explanation of this package is limited to the CBI. A thorough description of the entire package is added as annex 1.
Classroom Based Intervention
This research will focus on the implementation of the CBI in Nepal. The choice for the CBI and its implementation in Nepal as the focus of this research is motivated by the following reasons: the CBI implemented as a pilot in Nepal is the intervention within the Package best
6 http://www.tponepal.org/index.php?option=com_content&view=article&id=4&Itemid=7&lang=en 7 http://www.healthnettpo.org/nl/1311/psychosocial-care-package-children.html
evaluated. The overall evaluation of this intervention is of high quality, due to its Cluster Randomised Controlled Trial (CRT) and its conservative cut-off points (Barry et al, 2013;
Jordans, 2014). The significant and robust treatment effect on behavioural change indicates potential for a research into the possible effects of MHPSS on peacebuilding (Jordans, 2013).
In the following section the CBI will be explained in detail.
The CBI is a protocolised group intervention, consisting of 15 sessions, each of an hour. The CBI consists of a mixture of CBT (Cognitive Behavioural Therapy), creative-expressive and experimental therapy. The CBI combines psychological techniques such as psycho-education, trauma-processing activities through drawing and activities that promote group cohesion. The aim of the CBI is twofold: first, to reduce psychosocial distress and the risk of developing psychiatric problems. Second, to increase social skills, positive aspects of psychosocial well- being and to promote resilience and empowerment (Jordans et al, 2010). The CBI is implemented as a pilot, in 4 districts of South-Western Nepal. These districts directly border India, and belong to the Terai, an area highly affected by the Nepalese conflict. The participants of this study were school going children, in the age of 11 to 14 years. The sampling strategy took place randomly and resulted in a selection of 8 schools with a total of 1367children. From these children 149 were absent, 30 refused, leaving 1188 children. These 1188 have been screened on the inclusion criteria through the use of the Child Psychosocial Distress Screener (CPDS) general psychosocial distress, which resulted in 325 children, spread over the 8 different schools. Random selection took place among the eligible children on these different schools, appointing children at 4 schools to the experimental condition (n=164) and the children on the other 4 schools to the waitlist condition (n=161). Of these children 167 were boys (51, 4%), and 158 were girls (48, 6%) (ibid.).
The research objective of this thesis is twofold: first, to investigate the potential of those who participated in the CBI to contribute to cultural peacebuilding in the areas of its implementation. And second, to investigate to which extent the CBI can contribute to the human security and ultimate sustainable peace in Nepal8. This research aims to answer the following research question: To what extent can the providence of MHPSS through the Classroom Based Intervention contribute to the promotion of cultural peace, and to what extent can this intervention then contribute to sustainable peacebuilding in Nepal?
The overall research question will be answered through the following sub questions:
8 With Nepal the communities where the CBI is implemented are meant.
1) The CBI aims to reduce psychosocial distress and the risk of developing psychiatric problems, and to promote aspects of psychosocial well-being among children affected by violent conflict. To what extent did the CBI affect variables that can possibly contribute to the process of cultural peacebuilding?
2) One of the intriguing results of the CBI is the effect of the intervention on the decrease in aggressive behaviour for boys and the increase of prosocial behaviour for girls (Jordans, 2013). What can these children mean for, or to what extent can the implementation of the CBI serve the process of cultural peacebuilding in the areas of its implementation?
3) Human security is of use and necessary even, to promote individual well-being and grassroots or bottom-up peacebuilding. To what extent does MHPSS contribute to human security and vice-versa? In other words, to what extent are these concepts interrelated?
4) To what extent then can the CBI have potential to contribute to human security, and ultimate sustainable peace in Nepal?
5) What do the findings of this research implicate for the (possible) link between MHPSS and peacebuilding, and what does this indicate for MHPSS program design and the humanitarian field in general?
Relevance
This research is of relevance because as explained in the problem statement, the exact relation between MHPSS and the process of peacebuilding and other forms of social transformation is still unclear. The CBI and the care package in general appear to be a promising intervention design. The multilayered approach, the integration into general (healthcare) facilities and the overall good evaluation of the package indicate a promising, evidenced based intervention.
The investigation into the possible contribution of the CBI to peacebuilding is therefore both interesting and relevant: the potential contribution of such an MHPSS program to social transformation can contribute to the accumulation of knowledge concerning the possible link between MHPSS and peacebuilding. Finally, it can contribute to the development of best practice into the field of MHPSS and future intervention designs for humanitarian assistance in general.
Methodology
The methodology used to answer the research question is a literature analysis. Sources used are academic literature, empirical research, reports and conversations with one of the creators of the psychosocial care package. The literature, research and reports are retrieved through the following data engines: Google Scholar, Pubmed and PsycINFO. The conversations with Mark Jordans are retrieved through telephone conversations and an appointment at Healthnet TPO in Amsterdam. The conceptual framework used for this analysis is based on Galtung’s theory of sustainable peace (1975) and the human security approach. Galtung’s theory of sustainable peace is applicable because it explains the several components required for a conflict society to move to sustainable peace. The human security approach appears to link directly to this theory: peacebuilding needs to be tailored to the needs of the people in order to be sustainable.
Limitations
As with most of the research into the field of humanitarian action, it is hard to investigate certain phenomena without going into the field. Due to temporal and financial constrictions the analysis of the treatment effect of the CBI is based on secondary empirical data, not specifically collected to assess its treatment affect on peace tendencies. The dataset of Healthnet TPO is rather extensive and highly reliable. However, it does limit the extent to which the data can provide an answer to the questions posed in this research. Another limitation to this research is the feasibility of investigating the process of peacebuilding within a particular setting without empiric investigation.
Chapter 2. Theoretical framework
The theoretical framework used in this thesis is twofold: the theory of sustainable peace by Galtung, and the human security approach. These concepts are explained thoroughly in this chapter. The concepts of MHPSS and reconciliation, likewise require further explanation, and are therefore added to this theoretical framework as well.
2.1 MHPSS
MHPSS is a composite term to describe any type of local or outside support that aims to protect or promote psychosocial well-being, and treat or prevent mental disorders in conflict or disaster settings (IASC, 2007). The field of MHPSS is relatively new (Tol et al, 2013). The importance and relevance of the providence of MHPSS in humanitarian contexts and development strategies has been acknowledged by the international community, and MHPSS programs and activities are integrated into humanitarian and general health care programs more often since the last couple of years (Tol et al, 2011). There used to be much disagreement between different practitioners in the field concerning the views on best practice. Schauer & Schauer among others proclaimed a focus specifically on mental health, to address the high prevalence of mental disorders among these populations with evidence- based interventions (Schauer & Schauer, 2010). Others advocated for a psychosocial intervention approach, putting more emphasis on the interaction between the psychological state and the social environment (Clancy & Hamber, 2008). It was finally agreed that both mental health and psychosocial support are important to fully preserve and promote the well- being of those in conflict and disaster settings. In order to promote improvement in the coordination of MHPSS, and to prevent harmful interventions and polarisation within the field of humanitarian assistance, the World Health Organisation (WHO) took the initiative to come to an agreement on best practice through the creation of guidelines for the implementation of MHPSS. This initiative has been formally established in 2007 by the creation of the Inter Agency Standing Commission (IASC) guidelines for Mental Health and Psychosocial Support in Emergency Settings. These guidelines are based on the expertise of several practitioners in the field of MHPSS, and aims to advise those who work in humanitarian settings on appropriate ways to address the needs for MHPSS (IASC, 2007).
The majority of intrastate conflicts take place in Low and Middle Income Countries (LMCs).
These conflict affected areas often have limited (financial) capacities to generate health care
systems in general, let alone mental health care (Jordans et al, 2010a). Failing institutions, an impaired infrastructure, poverty and security issues highly affect the access to and providence of mental health care (Jordans & Tol, 2012). Non-Governmental Organisations (NGOs) that provide MHPSS can fill this gap. However, in order to address these problems successfully as an NGO, one needs to know how to construct these interventions effectively. A multi-layered mental health care system provides comprehensive MHPSS to different sub-populations based on their specific mental health care needs and their own resources available. Lower cost interventions are provided first, and only when this is not sufficient one receives more expensive specialised treatment (Jordans et al, 2010a). This multi-layer healthcare approach is illustrated as an intervention pyramid in the IASC; this intervention pyramid is added as annex 2. MHPSS programs generally adhere to these IASC guidelines in program and intervention design. Reason for advocating for a multi-layered approach is that societies as a whole are often highly affected by war and violent conflict and often are in need for some form of mental health care (IASC, 2007 ; ibid. ). However only those who develop psychosocial distress require a more specialised intervention, and only a minority will develop a mental disorder as a consequence of exposure to conflict and requires specialised individual mental health care. A multilayer healthcare approach is also more cost-efficient (Jordans et al, 2010a). MHPSS projects are ideologically implemented in general health care systems, public and social services or the educational services, in order to be sustainable. MHPSS services are often implemented through humanitarian funding, which is time-bound. If implemented without an existing service or institution, one is not sure about its permanence (Tol et al, 2011). Therefore, the challenge of implementing MHPSS programs is to both integrate mental health care into existing health care systems, to take a multi-layer approach, and to work with and anticipate the psychosocial community support mechanisms at the local level (Jordans et al, 2009).
2.2 Sustainable peace
The concept of ‘sustainable peace’ was first coined by Johan Galtung (1975), who argued for a conflict resolution approach that would address the root causes of a conflict, and would create local capacities for peacebuilding. Sustainable peace is essential: countries that suffered an intrastate conflict have a 44% change to relapse back into violent conflict within 5 years.
The reason for this high percentage is twofold: the underlying causes for the initial conflict have not been addressed, and there is a lack of local capacity for peace (Collier & Hoefler,
2006). Sustainable peace is therefore pursued in order to prevent future conflict (Ramsbotham, Woodhouse & Miall, 2011).
Sustainable peace is an idealistic end-goal of a peacebuilding process, whereby peace is stable and return to violent conflict is unlikely. Part of the creation of the concept of sustainable peacebuilding is based on the triangle of conflict, also created by Galtung (1975 & 1990). The figure of this concept is included as annex 3. According to Galtung, three components must be present in order for a conflict to arise. First of all, there must be a structural cause. Bad governance, human rights or land disputes are among the many possible foundations for a structural opposition between different opposing parties (Ramsbotham, Woodhouse & Miall, 2011). This structural opposition often leads to a second component: change in attitudes between these opposing parties. Stereotyping, dehumanising attitudes that are influenced by intense negative emotions as fear, anger and grief. These violent attitudes often serve as the justification and the lack of remorse for coercive measures, and can therefore fuel the use of violence (ibid.). The third component then is the direct use of force then is defined as direct violence: the actual use of force and conflict behaviour. In a full blown conflict these three components are all interrelated and reinforce each other. The use of force contributes to new structural problems as scarcity, and further promotes negative attitudes between the opposing parties (ibid.) Peace is often initiated by direct peacebuilding, which involves an absence of direct violence or conflict behaviour. This is often pursued through a cease of fire or a peace agreement (ibid.). After this early recovery phases a post-conflict society moves into a transitional phase. This stage in the peacebuilding process is defined by Galtung (1990) as
‘negative peace’: violent conflict has ended, or has gone into remission. The transformation of a conflict situation to a transitional situation is usually initiated by a peace agreement. At this stage however one cannot speak of sustainable peace. Although the armed fighting has come to an end, there is still a high level of insecurity (Harrof-Tavel, 2003).
Societies in transition may remain stable and move towards long term peace. This requires a process of deep conflict transformation. In order to promote sustainable peace, defined by Galtung (1990) as ‘positive peace’, the structural, underlying causes of a conflict need to be addressed. Galtung refers to this process as ‘structural peacebuilding’. Structural peacebuilding involves good governance, the promotion of human rights and addressing the problems that were the foundation for the conflict. Structural peacebuilding must be induced from the top, and must address the root causes of the conflict at a social, political and economic level, and throughout all ethnic groups and different levels of society. Policy
change, the promotion of human rights and good governance are therefore prerequisites for structural peacebuilding. Top level leaders and organisations both have the power and the responsibility to address the structural problems as part of the conflict (Ramsbotham, Woodhouse & Miall, 2011). Attitudinal change, defined as cultural peacebuilding, is the final component that requires change in order to reach a process of deep conflict transformation.
Cultural peacebuilding is only reachable if processes of social change come about, that involve at least a certain level of reconciliation. Cultural peacebuilding is promoted through the strengthening of civil society, the promotion of community relations and ultimately social cohesion, and the change of polarised attitudes by projects that involve cross-cultural work (ibid.) Cultural peacebuilding must be promoted from the grass root level, through individuals and communities (Lederarch, in Ramsbotham, Woodhouse & Miall, 2011).
John Paul Lederarch developed a different concept to approach sustainable peace. Lederarch puts less emphasis on structural change, and argues that sustainable peacebuilding must be approached from the bottom up, through the empowerment of civil society and the direct participation of those who have been affected by the conflict. NGOs and local leaders are key actors in the promotion of grassroots peacebuilding (Lederarch, in Ramsbotham, Woodhouse
& Miall, 2011). This bottom up approach however also received critique, in that it would be putting too much emphasis on addressing grassroots level peacebuilding, hereby neglecting structural issues.
2.3 Human Security
A more appropriate approach to address direct, structural and cultural peace simultaneously appears to be the ‘human security’ approach developed by the United Nations (UN) in 1994 (UNDP, 1994). ‘Sustainable peace and security can only be achieved if shared by all’ (Palme, in Zwitter et al, 2011). The concept of human security emerged in the post-cold war era, in addition to the concept of ‘traditional’ or ‘state security’. The traditional concept of security puts its emphasis on the security of the (nation) state: its consistency, territorial integrity and the absence of external threat. National or state security is therefore promoted through investments in military defence, military machinery and state building. In this traditional concept of security, the continuity and security of the state are put before the security of its society (Zwitter et al, 2011). State or national security solely involves states as the actor, through the decision making process of the government. The human security approach on the other hand is people centred, with an emphasis on the security and well-being of individuals
and their communities. The concept of human security is divided over seven areas: food, economic, political, health, environmental, personal or physical, and social or community security9 (UNDP, 1994). Threats to one of these areas can be defined as a threat to human security, and deserves special attention. The promotion of human security involves not only governments: it likewise involves national and international organisations, NGOs and local communities (Michael, 2002).
The development of the concept of human security has led to two different schools of thought on what constitutes best practice when focusing on human security: the ‘Freedom from fear’
school on the one hand and the ‘freedom from want’ on the other. Supporters of the idea that human security should focus on freedom from fear argue that human security should limit itself to the protection against violent conflict, through humanitarian (emergency) assistance, conflict prevention, conflict resolution and peacebuilding (HSRP, 2011). Those who support the idea of freedom of want extent the focus towards development, and argue that security should in addition to protecting against conflict, focus on the protection from diseases, hunger and other threats to the security of the individual. The idea of human security is then to alleviate poverty and to create public services delivery, because this will ultimately lead to peace and stability (ibid.).
A threat to human security is a direct threat to both the objective and process of sustainable peacebuilding. It undermines the legitimacy of reconciliation and peacebuilding, and fuels both the structural and attitudinal motivations for conflict (Richmond, 2007). Peacebuilding strategies must be tailored towards the needs of a specific post-conflict area, and towards the local needs and conditions. The human security approach aims to address both the deep causes as the long term consequences of a conflict, as national security often said to only address the direct consequences of violent conflict. Paying attention to basic and everyday human needs, personal well-being, livelihoods and other facets of human security would tailor the process of reconciliation and peacebuilding more to the daily needs of individuals and communities. Using the concept of human security would help to identify these needs, and is useful in the determination of project goals to promote sustainable peace (Newman, 2011).
Therefore one can argue that a human security approach is the way through which sustainable peace can, and must be reached: the improvement of human security is central to peacebuilding (ibid.). It links to the question of local legitimacy for peacebuilding. The focus
9 The definition of the seven security sectors differ between the human security report by the UNDP and the comprehensive security handbook by Zwitter et al. In the rest of this thesis the definitions of Zwitter et al, physical and social security are used.
on human security however does not implicate a conflict with state or national security. The state remains the central provider of security through its government and institutions (Richmond, 2007). NGOs, together with regional and local leaders, are key in the human security approach: they promote human security, and can help facilitate human security needs in areas where the government or national institutions are either incapable or unwilling to provide these. One of the priorities of NGOs is therefore to enhance and promote institution building, and the providence of services that promote human security through public service delivery (Michael, 2002).
The human security approach also suggests that peacebuilding beholds more than physical security and material resources, and must address social relations and the restoration of trust (Newman, 2011). The way individuals relate to each other is of major importance to the level of social cohesion and sustainable societies. The promotion of social cohesion can be as critical for well-being and security as economic development is (UNDP, 2013). As already mentioned before, social security is one of the distinctive areas within the concept of human security. The concept of social security refers to the provision of basic needs through either a group or a social network, and is based on the idea that most people derive social security from membership of a social group, network or community. These social groups do not only provide security in the form of social support, they can also provide practical support (ibid.) The social security approach commits itself to the exchange, helping and sharing of social behaviour and interaction, and is used as an indicator to measure the social networks and connections. Those affected should be approached through a holistic social picture: as part of groups, networks and communities. A social security approach to peacebuilding implies the promotion of trust building (Newman, 2011). Indicators of social security are the level of social cohesion, tolerance and inclusion, all important factors for cultural peace. It therefore appears that social security links directly to cultural peace.
It is of significant importance that a human security approach, among others, promotes reconciliation. A human security stakeholder’s analysis is of use to identify what is needed in order to promote sustainable peacebuilding. A failure to include one of these local needs can leave people marginalised, prone to manipulation and conflict prone propaganda, and unlikely to support reconciliation initiatives (ibid.). Social security in this regard is the identification of community needs: what is required in order to promote reconciliation within, and between communities?
2.4 Reconciliation
Cultural peacebuilding concerns attitudinal change and the restoration of social and interpersonal relations. The promotion of cultural peacebuilding involves the promotion of social cohesion and the creation of a common ground between opposing groups (Ramsbotham, Woodhouse & Miall, 2011). This process of social transformation is often defined as the process of reconciliation. Reconciliation however is an ambiguous concept.
First of all, there is a lack of consensus about the actual definition of reconciliation (Bloomfield, 2006; Brouneus, 2008). Due to this ambiguity the concept and implementation of reconciliation is different across settings, sometimes leading to misconceptions or implementations of reconciliation programs that do not fit within the local context (Peace Building Initiative, 2013). Moreover, national and cultural norms regarding human rights, justice and peace can vary between different areas, consequently leading to a different understanding of how to pursue reconciliation and sustainable peace (Eastmond, 2010). This lack of consensus can largely be attributed to the discussion if reconciliation should be defined as a process, or as a final stage. Many scholars as Lederarch argue that reconciliation should be understood as a process rather than a final stage because reconciliation as final stage is a long term process, and true reconciliation between former opposing groups is often too idealistic.
The use of the term ‘reconciliation’ often leads to resistance among those who have been affected by violent conflict. The term reconciliation often implies forgiveness and coming to terms with the former enemy, which those affected are often neither ready, nor willing to do.
‘Coexistence’ is gaining popularity as a substitute for reconciliation. A certain level of peaceful coexistence is a minimum requirement for peacebuilding, and reconciliation may come later, after trust has been rebuild. This also lowers the risk of resistance (Bloomfield, 2006). Reconciliation then becomes a process of building relationships between former opposing parties and those affected by the conflict to live in peaceful coexistence: living together, having mutual tolerance and a certain level of respect (ibid.) This approach to reconciliation appears to be the most appropriate to post-conflict societies, and thus will be used throughout the rest of this thesis when speaking of reconciliation.
Reconciliation after violent conflict is the most daunting challenge in a post-conflict society.
Often too much has happened in forms of loss and trauma for reconciliation to be feasible (Ramsbotham, Woodhouse & Miall, 2011). Reconciliation efforts however have significantly
increased since the last decade: the efforts undertaken to pursue reconciliation have almost become an implicit part of the peacebuilding process in post-conflict societies. This process of healing starts at the individual level, addressing trauma and psychological recovery (Brouneus, 2008). The main emphasis of the process of reconciliation is therefore situated at the grassroots or community level, whereby the process of healing of those who have been affected by the conflict is of significant importance (Lederarch, in Ramsbotham, Woodhouse
& Miall, 2011).
Chapter 3. Context of implementation
Before moving on to the empirical chapters, it appears to be both useful and necessary to provide a thorough description of the context of implementation. Additional factors that are of relevance to the mental health and psychosocial well-being of the Nepalese people are explained as well.
3.1 Setting
Nepal is a country in South Asia landlocked by China (or Tibet) and India. The total population of Nepal approximated 27, 5 million people in 2012. The Nepalese population is very heterogeneous, with more than 60 different ethnicities within its borders, speaking 32 different languages (Kohrt et al, 2012). The official domestic language is Nepali, which is spoken by 60% of the population (Tol et al, 2005). Nepal is the poorest country in its region, with 31% of its population living below the poverty line. Mental health services created by the government are scarce in Nepal. Only 3% of the annual Nepalese budget is allocated to health care, and of this 3% only 1% is allocated to mental health services. Especially in rural areas mental health care facilities are hardly present (Tol et al, 2010).
3.2 Civil war
Nepal was involved in an intrastate conflict situation for over 10 years. The conflict started in 1996 when the Unified Communist Party of Nepal (UCPN), also referred to as Maoists, declared war against the central government of Nepal. The war in Nepal is characterised as a revolutionary war, whereby the Maoists aimed to overturn the established government (Stewart & Brown, 2007). The main causes leading up to this conflict were bad governance, especially in the more remote and rural areas, and dissatisfaction with the sub-ordinate position granted to women and lower castes in society. The conflict ended in November 2006 with a peace agreement between the Maoists and other political parties. Since the peace agreement Nepal has been in a transitional phase, aiming to transfer to sustainable peace (Subedi, 2013).
As with most of the contemporary conflicts, the civilian population was highly affected.
During the conflict over 16.000 people died. Moreover, crimes against humanity were
committed by both sides (governmental forces and opposites). Torture, executions, and many disappearances were prevalent: during 2003 Nepal suffered the highest level of disappearances in the world (Luitel et al, 2012). These horrendous events have had an impact on the psychosocial distress and the prevalence of mental disorders in Nepal (Kohrt et al, 2010). Even if not being directly affected by violence and human right violations, daily stressors that accompany intrastate conflict negatively impacted the psychological well-being of those living in areas directly affected by the war (Tol et al, 2010). The violent conflict therefore had a detrimental effect on the mental health and psychosocial well-being of the Nepalese people.
3.3 Mental health and psychosocial well-being
When looking into the effects of war on the prevalence of mental disorders and psychosocial problems one must be aware of the prevalence of these problems already present in a population before the onset of violent conflict. Though the prevalence of mental disorders such as depression and anxiety vary widely across different countries and societies, there is always a general prevalence of people who suffer from mental disorders, regardless of humanitarian emergencies (Sadock & Sadock, 2007). An average of 8% to 12% of people suffers from depression during the course of their life; this is 14 % to 18% for anxiety disorders (Kessler, Berglund & Demler, 2003; Kessler et al, 2005). In LMICs in general, mental health is associated with personal and interpersonal factors such as poverty, gender and education (Tol et al, 2010). Moreover, the effects of political violence on the general mental health of people affected also depend on the intensity of the conflict and the level of traumatic experiences one encounters. This is especially true for the risk of developing PTSD;
the amount and intensity of traumatic experiences are the strongest predictors for PTSD (Ozer et al, 2003). One does however not automatically develop a mental disorder as a consequence of grave and traumatic life events. An estimated 10% of the people develop PTSD after a traumatic experience (Kleber, 2008).
Luitel and colleagues (2012) conducted a study concerning the impact of the violent conflict on the mental health (the prevalence of PTSD, depression and anxiety) of the general Nepalese population. They found the following results: 73% of the respondents (n= 720) experienced exposure to people being killed in the period of 6 months prior to the survey, 70% experienced being physically hurt, 68% witnessed people being harassed. In order to identify the effect of the violent conflict and related traumatic experiences on the mental
health of the conflict affected population, one needs to have information regarding the prevalence rates among the conflict affected population both before the onset of violent conflict (which serves as a baseline) and the results measured during and after violent conflict.
Making an assessment of the increase of the prevalence of mental disorders attributable to the effects of violent conflict is a challenge because there is often no data available of the period preceding the onset of conflict and violence, especially not in low-income countries that are often marked by a lack of psychiatric surveillance (Kohrt et al, 2012).
Nepal is the first low-income country where data has been collected regarding the prevalence of mental health care problems both before and after violent conflict, where the same group of individuals has been assessed. The prevalence of anxiety and depression was measured in 2000 (although involved in an intrastate conflict, before 2000 many Nepalese were not majorly affected by the conflict situation) and in 2007 and 2008, after the signing of the peace agreement (Tol et al, 2010). Among this group (n= 298) the prevalence of anxiety rose from 26, 2% to 47, 7% during and after exposure to the conflict, whereas the prevalence of depression rose from 30, 9% to 40, 6%. The prevalence of PTSD after exposure to the conflict was 14, 1% (Kohrt et al, 2012). The increase in mental health and psychosocial problems is not solely caused by the Nepalese civil war though. Results of a measurement of an increase in the prevalence of depression in a population affected by the civil war in Nepal showed that although depression rates increased from 30, 9% to 40, 6% , this was highly attributable to the ageing of the population (ibid.) Regardless of the determinants contributing to the increase of prevalence of mental health care problems, there is a vast rise in mental disorders among this population, and the high levels of anxiety and depression among the population of Nepal assessed is one of concern (ibid.)
Mental health in Nepal has been associated with ethnicity (Kohrt et al, 2008). How these two factors interrelate requires further investigation though. Thapa and Hauff (2005) found lower prevalence rates of PTSD among lower caste Nepalese refugees compared to higher caste populations. Based on their results they concluded that being from a low caste appears to be a protective factor against the development of PTSD. This result however requires further investigation, and is not found in other research that investigated the prevalence of mental disorders among different castes in Nepal. Kohrt and colleagues (2012) found different results: being from a lower caste in Nepal is a high predictor for psychological problems.
They found that the prevalence rates among lower caste are 2, 5 times higher for depression, and 4 times higher for anxiety than among higher castes. They likewise argue that the
experience of war trauma does not further enhance the prevalence of mental disorders among lower caste Nepalese people. The prevalence of mental disorders among lower caste populations is high in general, and is not affected by having experienced traumatic events during the conflict. Based on these contradictory findings one can argue that in order to gain more clarity about the interrelation between mental health and ethnicity in Nepal, more research is required. One can also argue that this apparent link is rather one between socio- economic status and mental health, instead of one between ethnicity and mental health; a lower caste generally predicts a lower socio-economic status (Kohrt et al, 2009). It can therefore be a valid assumption that socio-economic status serves as a mediating variable within this relation: without the causal relation between caste and socio-economic status, the link between mental health and ethnicity in Nepal might not exist. This is also what Kohrt and colleagues found: when controlling for poverty and the experience of traumatic events as possible mediating variables there was no causal relation between caste and depression for Nepalese people. This conclusion would also be in line with the established association between mental health and socio-economic status globally (Smith et al, 1992). Regardless of the nature of this correlation or the mediating variables, there appears to be a difference between different ethnicities and mental health in Nepal. It is therefore of interest to take ethnicity into account when assessing the mental health and psychosocial well-being of the Nepalese population (Kohrt et al, 2008).
3.4 Children
One of the major consequences of the violent conflict is the threat to child development (Tol et al, 2010). According to Jordans (2010a) the civil war in Nepal led to the impairment of the psychological and psychosocial well-being of children; children lost their parents or other close relatives, were involved in violent and humiliating actions, and as is common to children in conflict areas, were frequently exposed to violence and humiliating acts. The results of a cross-sectional design between Nepalese children conscripted by armed groups and Nepalese children who were not conscripted by armed groups (who did live however in an area highly affected by the conflict) found a prevalence of 24, 1% for depression, 37, 6%
for anxiety, and 20% for PTSD among those who have never been recruited as child soldiers (Kohrt et al, 2008). The prevalence rate of other psychosocial problems was 44, 7%. War- related trauma and distress are not the only determinants for the psychological well-being of these children. Psychosocial factors such as age, gender, socio-economic situation, level of
education and distress after the violent conflict also highly determine the psychological well- being of children affected by violent conflict (ibid.) For instance, a research conducted by Kohrt and colleagues (2012) indicates that older children experienced lower levels of depression, whereas living in an extended family rather than a nuclear family led to higher levels of depression.
A subgroup that deserves special attention is the group of children recruited as child soldiers.
The People’s Liberation Army (PLA), the Royal Nepalese Army (RNA) and the Communistic Party of Nepal (CPN) all recruited children into their armed forces. These children were used as soldiers, cooks, spies and for other jobs within the armed forces. An estimated 35% of the PLA forces were comprised of child soldiers, the level of child soldiers within the RNA forces was 10 % (Kohrt et al, 2008). Recruitment by either of the armed forces led to a severe negative impact on the psychological well-being of these children. The results of the cross- sectional design between Nepalese children conscripted by armed groups and Nepalese children who were not conscripted by armed groups found a prevalence of 53,2% for depression, 46,1% for anxiety, and 55,3% for PTSD among those recruited as child soldiers (ibid.) These results are significantly higher than those of children who have not been recruited.
3.5 Peace and security in Nepal
Although the violent conflict has officially ended, peace negotiations are still ongoing (Supreti, 2013). Space has somewhat been created for conflict resolution and the promotion of peace. The signing of the peace agreement has led to a significant change in the politics of Nepal, contributing to the establishment of a democratic political system. People enjoy more rights and political freedom, with less difference between ethnicity, casts, gender and religious affiliation (ibid.). Unfortunately sustainable peace has not been reached anno 2014.
Due to a lack of consensus there is still no constitution, which engenders political insecurity (ibid.) In November 2013 the Nepalese people voted for a new government that will form the Constituent Assembly and will devote itself to drafting a new constitution. The development of this constitution depends on how the different parties are capable of reaching a common vision and the level of commitment for writing a new constitution.
However, even a new constitution would not solve the current problems Nepal is facing. The political insecurity, high levels of poverty, low development and the legacy of the civil war still pose a threat to the human security of the Nepalese people (Khatiwada, 2013; Upreti, 2013). The risk of relapse into conflict is higher when the civil war ends through a negotiated settlement, as the one in Nepal, than when war ends through military victory. This is because a negotiated settlement can give rise to tensions between parties that can ultimately lead to renewed violence. Military victory destroys the organisational capacity of the loser to renewed violence, and is therefore more effective in bringing peace (Fumerton & Gould, 2010). This theory can give an explanation for the current political situation in Nepal. Since the peace agreement CPN (Maoist) groups have committed unlawful and illegal armed activities. These events contribute to a sometimes very unstable security situation. Extra- judicial killings, cases of torture and other human rights violations are still being reported.
Law enforcement and securing forces such as the police cannot perform their tasks properly, and therefore cannot assure peace and security. The rule of law is therefore not properly reinforced. The Terai area of Nepal is a more vulnerable area within this regard (ibid.) In the period between the signing of the peace agreement in 2006 and 2011, 4481 people were killed according to INSEC, a Nepalese human rights organisation (INSEC, 2008). The killing of journalists has also been reported, with a total number of 7 in 2011. Although the overall number of casualties is decreasing, the situation remains worrisome (Upreti, 2013).
Living in a culture of violence that accompanies violent conflict has had an impact on the social security of the Nepalese people: social and cultural norms and values are negatively impacted. Instead a culture of hostility, mistrust and the use of violence as a means has rooted deep into society (ibid.) The restoration of the social fabric between people and the linking between the Nepalese people and the state, and the creation of a sense of safety and security is highly needed in Nepal (ibid.) The providence of MHPSS can be a meaningful factor in addressing these social security issues. Peace at community level remains a challenge in Nepal unless reconciliation conditions, together with addressing the psychosocial needs of those affected are met (ibid.) In order to promote the process of peace, former perpetrators and victims need to be reconciled at community level, in non-political and informal ways (ibid.) Along with reconciliation, psychosocial support to those affected by the conflict is needed. As already explained earlier, these needs are largely unaddressed in Nepal (Jordans et al, 2010a; ibid.).
An analysis of the peace and security situation in Nepal using Galtung’s theory of sustainable peace as introduced in the theoretical framework shows that the problems that are detrimental to the peacebuilding process in Nepal are mostly of a structural nature: the lack of political consensus and the failure to reinforce to the rule of law engenders political instability. This impedes the promotion of economic growth and development and the alleviation of poverty.
The issues that impede sustainable peace are however also of a cultural nature. The lack of psychosocial support and grassroots community building impedes the restoration of the social fabric and contributes to a lack of social security. These political and cultural issues undermine any attempt at securing sustainable peace, especially in the areas that were highly affected by the civil war.
Chapter 4. Treatment indicators
The first aim of this research is to investigate to what extent the treatment indicators of the CBI could potentially contribute to the process of cultural peacebuilding. In order to answer this question, the results of the CBI evaluation (Jordans et al, 2010b) are reported, and the potential of these results in their contribution to cultural peace are analysed consecutively.
4.1 evaluation of the CBI
As explained in the introduction to this thesis the aim of the CBI is twofold: first, to reduce psychosocial distress and the risk of psychiatric problems. Second, to increase social skills, positive aspects of psychosocial well-being and to promote resilience and empowerment.
Those implementing CBI aim to do this through enhancing constructive ways of coping, prosocial behaviour and hope (ibid.) In order to assess the treatment effect of the CBI Jordans and colleagues used the following outcome indicators: first, the decrease in psychiatric symptom, second, a reduction of psychosocial distress and behavioural problems and third, positive aspects of well-being, namely an increase in prosocial behaviour and a sense of hope.
Jordans and colleagues expected that the CBI would have impact on emotion regulation, stress reduction, behavioural adjustment and an increase of psychosocial well-being. In order to determine the effectiveness of the intervention and to what extent these three main objectives have been reached, the treatment effects have been measured with psychological measurement tools and questionnaires. The difference between the scores on these tests served as treatment effect indicators. The decrease in psychiatric symptoms was measured by the scores on the Screen of Child Anxiety Related Emotional Disorders (SCARED), the scores on Child PTSD Symptom Scale (CPSS) and the scores on Depression Self-Rating Scale (DSRS). The reduction of psychosocial distress and behavioural problems was measured by the scores on the Children’s Function Impairment (CFI), the scores on a subscale of the Aggression Questionnaire and the scores on the Strength and Difficulties Questionnaire (SDQ). The increase of positive aspects of well-being, namely an increase of prosocial behaviour and a sense of hope is measured by the scores on the Child Hope Scale (CHS) and
