Literature Review: Mental Health and Psychosocial Support in Transitional Justice in Africa

Introduction

This research publication provides a review of the peacebuilding and transitional justice literature on how MHPSS can and must be integrated into post-conflict reconstruction and restoration processes. It describes current approaches to peacebuilding and why transitional justice is a key component of peaceful and resilient post-conflict communities. The review details the limitations of current approaches that lack MHPSS components, highlighting the arguments that have been made for the integration of MHPSS and the improved outcomes it yields. Thereafter, it discusses the criticisms that have been made against this approach. Finally, it looks at future considerations for strengthening MHPSS within processes of transitional justice and peacebuilding, specifically areas that the Centre for the Study of Violence and Reconciliation (CSVR) and other civil society organisations can continue to develop in order to mainstream MHPSS in Africa.

Acknowledgements

A special thanks to our colleagues at the Center for the Study of Violence and Reconciliation – Jasmina Brankovic and Nomancotsho Pakade who have provided extensive inputs and critical reading of this piece. We also acknowledge Steven Rebello for beginning this project and paving the way to highlighting the contributions by scholars and practitioners within the fields of mental health and psychosocial support and transitional justice. Each of your inputs were essential to the project's completion. 

In 2020, the United Nations Office for the Coordination of Humanitarian Affairs (UNOCHA) found that '100 million people were in need of protection assistance due to conflict, violence, epidemics and climate-related disasters, or a mix of all four' (UNOCHA 2020, p.81). These events are often underpinned by human rights violations that have significant impacts on people's social, emotional and financial wellbeing and, ultimately, create lifelong effects on people's mental health. One in five people living in areas that have been affected by violent conflict have been found to experience significant mental health conditions like depression, anxiety disorder and post-traumatic stress disorder (PTSD) (UNDP 2022, p.5).

In certain contexts, survivors of violent conflict may reject terms such as trauma, depression, anxiety or PTSD to describe their mental states, for example because of the stigma surrounding mental health challenges or the sense that they are alien to their own cultural understandings of the impacts of violence. In response, some practitioners have called for recognition of more diverse terminology to describe the reduced psychological wellbeing that typically presents in those affected by conflict, instead of imposing language and experiences that are related to Western, individualised and biomedical notions of mental health (Brankovic 2021, p.8-9; UNDP 2022, p.22).

The relationship between mental health and psychosocial support (MHPSS) in conflict has gained increased recognition globally over the past two decades. Scholars and practitioners have called for the integration of MHPSS into peacebuilding and transitional justice processes through a clear, substantive framework (Tankik et al., 2017; Kubai and Angi, 2019; Arthur and Monnier, 2021; Brankovic, 2021; Hamber, 2021). This has yet to occur in a systematic manner.

This paper provides a review of the peacebuilding and transitional justice literature on how MHPSS can and must be integrated into post-conflict reconstruction and restoration processes. It describes current approaches to peacebuilding and why transitional justice is a key component of peaceful and resilient post-conflict communities. The review details the limitations of current approaches that lack MHPSS components, highlighting the arguments that have been made for the integration of MHPSS and the improved outcomes it yields. Thereafter, it discusses the criticisms that have been made against this approach. Finally, it looks at future considerations for strengthening MHPSS within processes of transitional justice and peacebuilding, specifically areas that the Centre for the Study of Violence and Reconciliation (CSVR) and other civil society organisations can continue to develop in order to mainstream MHPSS in Africa.

In addition to the literature, the paper is based on inputs from CSVR staff, who highlight the need not only for MHPSS but also for greater cross-pollination between the fields of transitional justice and peacebuilding, based on key learnings that have emerged in their work with various stakeholders across post-conflict contexts in Africa.

2. Current Approaches to Transitional Justice and Their Limitations

According to the African Union Transitional Justice Policy (AUTJP), transitional justice refers to the various (formal, traditional or non-formal) policy measures and institutional mechanisms that societies with legacies of violent conflicts and systemic or gross violations of human rights adopt in their efforts to overcome past violations, divisions and inequalities and to create conditions for both security and democratic and socio-economic transformation (AUTJP 2019,p.4). While each country develops its own goals for its transitional justice processes, the field is generally concerned with forging a path towards a peaceful, just and inclusive future where past crimes have been acknowledged and redressed, and citizens and leaders agree that violence and human rights abuses will never again happen (ICTJ, 2022).

Transitional justice tends to be structured around four core mechanisms: prosecutions, truth commissions, reparations and institutional reform. As a result, transitional justice is often treated as a mechanism-focused and technical process rather than a more comprehensive social intervention. Brandon Hamber (2021) argues that this approach has historically neglected or dehumanised victims by failing to provide holistic victim support. Although there have been some improvements in terms of participatory approaches and the increasing visibility of victims, the limited victim support raises questions about the effectiveness of attempts to rehabilitate and reintegrate communities and individuals affected by violent conflict.

While often considered separate fields, transitional justice and peacebuilding are interlinked. Catherine Baker and Jelena Obradovic-Wochnik (2016) acknowledge that transitional justice is more concerned with achieving or restoring justice, while peacebuilding is more concerned with bringing about peace. They note the complexities of the 'peace versus justice' debate, including arguments that quests for justice may hamper peace or, contrastingly, that peace can be achieved through justice.Another distinction that has been made is that although both transitional justice and peacebuilding look forwards and backwards, the former is generally seen as more backwards facing than peacebuilding.

Yet, Baker and Obradovic-Wochnik note that transitional justice is connected to peacebuilding as it seeks to build sustainable peace, for instance by ensuring non-repetition of violence and conflict through institutional reforms. Chandra Lekha Sriram (2007:579) has critised this assumption, however, as being disconnected from reality, whereby transitional justice processes can be destabilising and even provoke a return to conflict. They further argue that in some cases where transitional justice processes and mechanisms may be externally imposed and inappropriate for the political and legal cultures in which they are placed, they can destabilise post-conflict and post-atrocity countries, and produce unintended consequences. These two views demonstratethat the two fields developed largely in parallel to each other and they stillfeed into each other.

Looking at MHPSS in peacebuilding, Maryam Rokhideh (2017) criticises how it is often side-lined in practice due to peacebuilding focusing almost exclusively on macro-level activities such as state-level policies and institutional mechanisms rather then community and individual-level interventions. In her study on peacebuilding processes in northern Uganda, Rokhideh finds that 'psycho-social interventions have largely been short-lived, targeted at specific groups at the expense of others, failing to respond to the daily needs of the population, and remained relatively disconnected from the wider post conflict recovery process' (2017, p.215). Rokhideh's recommendation is that war-to-peace transitions should address the full range of conditions that affect societies emerging from complex emergencies. She argues that psychosocial interventions that are responsive to the needs that arise during this period must be at the center of such processes.

Similarly, Jan Ilhan Kizilhan and Johanna Neumann (2020) argue for an MHPSS-inclusive approach to transitional justice. They highlight the need to balance and differentiate between individual psychological healing and societal healing when evaluating the outcomes of post-conflict reconciliation processes, given that these are not the same thing. Looking at the case of Rwanda, Brounéus (2010) notes that at the societal level gacaca courts seem to have helped people to move forward, yet much less is known about their psychological and mental health effects on individual survivors. This raises questions about how to tackle individual- through to societal-level psychological impacts of conflict.

In addition, both peacebuilding and transitional justice have tended to focus too narrowly on the rehabilitation needs of victims to the exclusion of identified perpetrators and highlights the need to identify and refine the nexus between psychosocial approaches that can address this. In both peacebuilding and transitional justice, survivors tend to be narrowly viewed as victims rather than as having agency and thus being resilient, given the adequate support and appropriate available interventions. The notion of agency is crucial given the complications that arise when trying to determine who is a victim and who is a perpetrator. In times of conflict, particularly long-term or historical conflict, the lines between victim and perpetrator can be blurred. An example of this is where Corkalo et al. (2004) describe how after the Yugoslav wars, different national groups felt that their group was the greatest victim and that the International Criminal Tribunal for the Former Yugoslavia (ICTY) was against them. In this instance the victim-perpetrator lines were not clearly defined, which meant any interventions needed to take account of the implications for accountability, restoration and support.

3. Recommendations for Integrating MHPSS in Transitional Justice

Given the limitations detailed above, there is a clear need for integrating MHPSS as a core component of transitional justice and peacebuilding interventions. This means that MHPSS is not merely an add-on, but rather applied as a lens through which these processes are understood and structured. It requires the mainstreaming of MHPSS – making it a part of the existing processes and structures. This section describes the different recommendations that have been offered as potential pathways for MHPSS integration.

Focusing on transitional justice, Jasmina Brankovic (2021) details recommendations on how to create more contextually relevant MHPSS interventions, based on lessons learnt by CSVR and other practitioners in The Gambia. It is worth noting that MHPSS is a core focus for CSVR, meaning that MHPSS is in all aspects of its work in Africa. Brankovic demonstrates that MHPSS needs to be integrated into the support mechanisms of transitional justice measures, civil society and social services.

The recommendations include MHPSS interventions that acknowledge existing individual and collective resilience and means of coping. They also highlight how various identifying factors influence experiences and understandings of trauma. Additionally, they show need for inclusive approaches which prioritise high levels of local participation and ownership of transitional justice processes. Lastly, Brankovic highlights the value of thorough needs assessments, which can assist stakeholders in developing more contextually relevant and sensitive MHPSS interventions.

Hamber (2021) provides further critical considerations for the increased role of MHPSS in transitional justice. He notes the relevance of MHPSS to a 'people-centred' approach and how psychosocial concerns can inform transitional justice advocacy and programming. He posits that many MHPSS interventions emanate from a Western, individualistic and medicalised understanding of trauma and healing. Community interventions, meanwhile, tend to include aspects of participatory approaches, community resilience and resources, but are neglected in dominant MHPSS approaches.

Hamber argues that because of this gap between dominant and more community-driven approaches, MHPSS remains politically, socially, culturally and historically decontextualised. He suggests that this may be due to a lack of coordination and communication between intervening agencies and a lack of funding. It is also likely that the fragile, post-conflict political contexts in which these interventions occur greatly limit levels of critical consciousness of intervening actors and, consequently, the types of interventions that are allowed in such contexts.

Coming from a peacebuilding perspective, Paige Arthur and Celine Monnier (2021) also make an argument for greater integration of MHPSS. They reinforce the idea that the field of peacebuilding must recognise both physical and psychological impacts of conflict, noting that MHPSS approaches to peacebuilding remain anecdotal and ad-hoc. Arthur and Monnier recommend supporting state and non-state capacities to implement MHPSS interventions. This can include awareness-raising around the importance of MHPSS services and, similarly to Brankovic's recommendation, conducting thorough needs assessments to highlight the existing local and national capacities and gaps in implementing MHPSS.

Arthur and Monnier also emphasise the use of a contextually sensitive approach to recognising resilience, capacities and concepts of trauma and healing. They call for building expertise around MHPSS as an important part of preventing violence and sustaining peace, while noting the need for creative partnerships among transitional justice implementers that would support an integrated approach. This would include highlighting the nexuses between the fields of transitional justice and peacebuilding, as well as fostering collaboration between national through to international institutions linked to those fields.

UNDP (2022) argues, meanwhile, that MHPSS mainstreaming can provide critical support to victims of sexual and gender-based violence during and after conflict. It acknowledges the prevalence of war-related sexual violence and its consequences for mental wellbeing. As sexual violence is often used as a political tool in conflict, it is important to understand how it affects people's daily lives and the context-specific consequences and vulnerabilities that emerge. Some of these include genital injury, obstetric fistulae, sexually transmitted diseases (including HIV/AIDS) and unwanted pregnancies (Anderson and  Van Ee, 2019).

Furthermore, UNDP notes how during conflict, traditional or cultural gender roles can shift, with women taking up more traditionally male roles while men are away at war. When men return home, this can cause household conflict and become a catalyst for domestic violence. Transitional justice and peacebuilding processes that do not have a substantial MHPSS component neglect the treatment, care and support that victims of sexual violence require.

The call to integrate MHPSS into transitional justice and peacebuilding has increasingly been taken up by multilateral institutions. In the African Union's Transitional Justice Policy (2019), MHPSS interventions represent a central aspect of victim support, rehabilitation and reintegration. The United Nations (2020, p.11), meanwhile, promotes enhancing the integration of MHPSS into peacebuilding, stating that 'the further development of the integration of mental health and psychosocial support into peacebuilding is envisaged with a view to increasing the resilience and agency of people and communities.'

4. Expected Improved Outcomes from MHPSS Integration

The literature indicates that there is still not enough research on the use of MHPSS approaches in transitional justice and peacebuilding. However, there is growing evidence of the United Nations' efforts to use MHPSS interventions to foster peace. The Office of the United Nations High Commissioner for Human Rights has developed tools for ensuring that MHPSS is a key deliverable for both children and their caregivers in United Nations humanitarian aid programmes worldwide (UNOCHA, 2020).

One of the main expectations for the integration of MHPSS is prevention of cycles of violence, as the physical and psychological injuries that are experienced by individuals and communities in conflict can affect people across their lives. The psychological impact of conflict can be enduring, if not addressed. It can also be passed across generations through intergenerational trauma, with psychological injuries then affecting institutions in the public and private sectors.

Hamber (2021) points out that conflict and its physical and psychological injuries can have severe impacts at the individual, community and societal levels. Addressing mental health and its impact on the social fabric is vital to addressing collective trauma and achieving sustained justice and peace. Hamber notes how trauma and other mental challenges can be risk factors for violence and conflict when not addressed. Thus, MHPSS within transitional justice and peacebuilding can serve as a preventative measure for future conflict.

In addition, the United Nations Integrated Disarmament, Demobilization, and Reintegration Standards (IDDRS) recognise­ the importance of MHPSS to rehabilitating and reintegrating former combatants. Given that combatants are part of various systems within their social environment, according to the ecological systems theory, their rehabilitation is important not just for the individual but also for the people around that person. Once again, this shows that MHPSS is not only about the individual.

Another expected outcome for the mainstreaming of MHPSS is to incorporate a more people-centred or people-centric approach to transitional justice and peacebuilding. This speaks to the criticism of transitional justice that it is state-centric, while neglecting the community and individual needs of those affected by conflict. Mainstreaming MHPSS demonstrates that transitional processes are not just about politics, government and institutions, but also about individuals, communities and their different needs for everyday life, which need to be taken as seriously as high-level commitments. Such narratives of how conflict has longlasting impacts on everyday life are well-evidenced in the biographical narratives of survivors of conflict (e.g., Langa et al., 2021).

A people-centred approach to transitional justice, by extension, draws attention to the gendered dynamics of conflict-related injuries and trauma. There has been growing recognition that sexual violence is often deployed in conflicts as a form of physical and psychological warfare intended to punish, intimidate and destroy communities (Mureithi, 2020). In post-conflict settings, according to Samantha Bradley (2018:130), gender-based violence tends to increase as 'a result of harmful masculinities created by armed conflict, in combination with the psychological problems of combatants and civilians as a result of their experiences.'

Sexual violence affects all genders, but these experiences are often kept secret for fear of stigmatisation and re-victimisation. The United Nations Development Programme (2022) states that by integrating a gender-transformative lens, MHPSS can challenge these stigmas and confront the damaging effects of militarised masculinity. Gender dynamics can also be considered in operationalising the MHPSS-inclusive approach through practitioners adapting their approach to suit different contexts. As noted in Brankovic (2021, p.9), 'in patriarchal contexts … it may be preferable for men practitioners to work with men and women practitioners to work with women, both individually and in groups, in order to establish common ground and trust.'

Hamber and Gallagher (2015) offer a template for those dealing with the aftermath of armed conflict to look at peacebuilding through a psychosocial lens. Through case studies of contexts as diverse as Guatemala, Indian Kashmir, Northern Ireland and South Africa, they show that conflict and the political violence that flows from it are deeply contextual. They argue not only that MHPSS is not merely about treating individuals and groups with context-responsive and culturally sensitive methods, but also that such interventions and practices should in themselves shape and drive social change. This is of critical importance as psychosocial approaches continually demonstrate that social context is one of the primary causes of individual psychological distress. The common thread between the case studies is that they show how psychosocial interventions can influence the peacebuilding environment and foster wider social change.

5. Critiques of MHPSS Integration

The literature indicates that one of the main shortcomings of this approach is the dearth of research on MHPSS in transitional justice and peacebuilding. Kizilhan and Neumann (2020) note that there is little evidence of the implementation of MHPSS integration in specific contexts, particularly with differentiated outcomes of mental health and psychosocial support for individuals and communities. Where it has been phased in, the evidence is fragmented and not yet consolidated into a comparative study.

CSVR practitioners highlight the additional shortcoming that current approaches to MHPSS in transitional justice often make it culturally or contextually inappropriate. As noted above, MHPSS may be perceived as Western, overly individualistic and medicalised therapy that is not critical or transformative. It is still seen by some as unable to address the root causes or injustices that fuel conflicts.

Thus, the question remains: Does MHPSS take a justice perspective within existing post-conflict processes, or does it seek to achieve justice through post-conflict processes? One response is that MHPSS brings a trauma-sensitive and human-centred approach to existing transitional justice and peacebuilding initiatives. An argument that emerged from a CSVR symposium on integrating MHPSS in transitional justice is that many indigenous cultures are collective in their practices, and therefore able to heal in different ways. MHPSS practitioners can go into those communities and find what structures they already have in place so that they can support and build on them using an MHPSS lens (Brankovic, 2021).

There are a few examples where more contextually relevant MHPSS interventions have been co-created with affected individuals and communities in participatory ways, such as the Inter Agency Standing Committee's (IASC) engagements, detailed in the Guidelines on Mental Health and Psychosocial Support in Emergency Settings. The IASC approach focuses on building on existing community capacities and resilience so that MHPSS interventions are culturally and contextually appropriate. The IASC (2007) intervention pyramid for MHPSS in emergencies also proposes activating communal traditional support such as friends and family support networks as well as local and indigenous structures to integrate principles of emotional and practical care in post-conflict situations.

6. Conclusion: Future Considerations for Strengthening MHPSS

The role that MHPSS plays in justice and peace has gained increased recognition in the fields of transitional justice and peacebuilding, and in efforts to provide more holistic support to victims of violent conflict and support them through the adverse effects of the traumatic events they experienced. This includes recognition of how conflict contributes to physical and psychological trauma at various levels – individual, communal, institutional, societal – historically and across generations. It also includes recognition of how addressing these psychological traumas through the integration of MHPSS initiatives is vital to lasting justice and peace.

MHPSS offers healing for the individual and broader society and psychological support and rehabilitation for survivors, perpetrators and those who may occupy overlapping groups. There are other aspects of MHPSS that are useful that are not always prioritised in post-conflict contexts, such as prioritising access to services such as access to medical care and education.

Whilst this recognition has continued to grow, this literature review demonstrates the challenges and opportunities related to the intersections among MHPSS, transitional justice and peacebuilding in Africa. It highlights that mainstreaming MHPSS can provide better support for victims of sexual and gender-based violence who are often silenced or under-represented in post-conflict processes. MHPSS can help address the gendered dynamics relating to conflict traumas and injuries that conventional transitional justice measures may be poorly capacitated to address.

Finally, scholars and practitioners have detailed how the integration of MHPSS into transitional processes requires collaborative efforts and people-centred, culturally appropriate and gender-sensitive approaches that acknowledge regional commonalities and local nuances.

7.  References

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Anderson, K. & Van Ee, E. (2019). Mothers With Children Born Of Sexual Violence: Perceptions of Global Experts Regarding Support In Social Care Settings. Health Care for Women International, 40(1): 83–101.

Arthur, P. & Monnier, C. (2021). Mental Health And Psychosocial Support To Sustain Peace: Four Areas To Explore For Improving Practice. Center on International Cooperation. Available (Online): https://cic.nyu.edu/resources/mental-health-and-psychosocial-support-to-sustain-peace-4-areas-to-explore-for-improving-practice/ [Accessed November 2022].

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