JUSTICE AND PEACE BRIEF 01|2018 SOCIO-CULTURAL PERCEPTIONS ON VIOLENCE, SUFFERING AND MENTAL HEALTH IN SOUTH SUDAN Over the past decade, a wide range of national and international humanitarian, diplomatic, religious, human rights, media and academic actors have increasingly referred to South Sudan, as ‘a traumatized nation’1, a notion that extends to historical and contemporary South Sudanese refugee and diasporic communities, and has intensified with the outbreak of renewed conflict in December 2013. Both in global and more localized SUMMARY discourses on how conflict affects South The effects of prolonged conflict on South Sudan Sudanese, suffering has become are predominantly viewed through a narrow lens synonymous to traumatisation. The of trauma. ‘nationalization’ of trauma consolidates This has contributed to a homogenization of the metanarrative of violence and diverse everyday lived experiences and sociocultural processes through which people emergency that has defined scholarly and recognize, experience and express suffering and humanitarian discourse on the Sudans for imagine recovery. decades and is grounded in the Although there is a growing body of quantitative, assumption that the majority of South neuroscientific research on the mental health Sudanese is traumatized by their impact of conflict in South Sudan, this research experiences with past and present-day project is among the first to study mental health violent conflict and structural violence. using a qualitative, social scientific approach in South Sudan. This brief does not question the reality of This brief suggests that for mental health suffering and experiences with interventions in South Sudan to be relevant and destruction, violence and death: many effective it is critical to gain a better citizens of South Sudan, throughout their understanding of the processes through which lifetimes, have experienced continued trauma has become embedded in everyday exposure to crisis and insecurity. vocabularies and has been adapted with different However, our understanding of the cultural and symbolic meanings. interconnection between violence, suffering and mental health is grounded in a more contextual, intersubjective and intersectional approach and is attentive to cultural idiosyncrasies. South Sudan is a multicultural, multi-ethnic and multi-religious nation and because of historical experiences with displacement and the diverse life trajectories of people, even within one particular social or ethnic group there is no singular way in which people make sense of suffering. 1 Among many examples, Amnesty International in a 2016 study titled ‘“Our Hearts Have Gone Dark”: The Mental Health Impact of South Sudan’s Conflict’, uncritically titles a sub-chapter “South Sudan: A Traumatized Nation.” | Trauma Identification and Humanitarian Interventions The characterization of South Sudan as a traumatized nation implies that (unresolved) historical and intergenerational trauma excites present episodes of violence. Ingrid Breidlid and Michael Arensen (2014, 7), for example, argue that “limited trauma-healing programs and the lack of a national reconciliation process until recently have contributed to the transfer of the culture of violence and historical grievances to younger generations” and a joint South Sudan Law Society (SSLS) and United Nations Development Program (UNDP) survey (2015, 1) noted that “the mental health consequences of decades of trauma are among the many factors driving the current conflict.” In an ambiguous manner, trauma has become an explanation - and at times justification - for ongoing violence and this has come to define the biographical facts of individuals and the entire nation (Breslau 2004), reducing people to a state of vulnerability and incapacitation. The concept of trauma to describe painful and tragic events, personally and collectively, is a relatively recent invention and over the past decades became globally used and integrated in multiple cultural contexts, both in medical and social spheres. During the late 1980s and early 1990s, the trauma concept and the interrelated Post Traumatic Stress Disorder (PTSD) gained universal prominence and PTSD became rapidly diagnosed in diverse local contexts. In South Sudan, like in many other humanitarian settings, a clear connection can be established between increased trauma identification and humanitarian interventions. In the midst of the second war (1983-2005), trauma and PTSD were introduced to thenSouthern Sudanese aid recipients inside Sudan and among refugees in neighbouring countries and diaspora communities in the United States, Canada and Europe. Despite the prevailing characterisation of South Sudan as a traumatized nation, there is relatively little data available about the prevalence of PTSD among South Sudanese. During the second war, a dozen of surveys were conducted with the aim of identifying levels of IJPS Justice and Peace Brief 01|2018 PTSD and depression among Southern Sudanese refugee and displaced communities (Karanukara et al. 2004; Neuner et al. 2004 ; during the second interbellum period similar studies were conducted among urban populations in various cities in South Sudan (i.e. Juba, Torit and Aweil) (Ayazi et al. 2012; Roberts et al. 2009; Winkler 2010); and after the outbreak of renewed conflict the focus of these studies shifted and extended to people displaced to Protection of Civilian (PoC) sites across the country (Deng et al. 2015; Deng et al. 2015b). For example, between 1988 and 1994, successive assessments were conducted among a mobile group of so-called unaccompanied minors, following them from Pinyudo in Ethiopia to Kakuma in Kenya. These studies, although they focus on a similar segment of Southern Sudanese refugee populations, reach opposing conclusions about existing levels of posttraumatic stress and need for mental health intervention. Between September 1988 and November 1990, RaddaBarnen, the Swedish branch of Save the Children, found that 1% of the children who were enrolled in a preventive mental health programme ran in Pinyudo refugee camp needed treatment for mental disturbances (Nilén 1994, 7). A study conducted in 1993 by the United Nations International Children’s Emergency Fund (UNICEF) among a similar group of unaccompanied minors in Nasir and Kakuma finds that 96 out of 174 (55%) minors ‘assessed’ were in need of extensive intervention because of PTSD. The UNICEF results are disputed by a team of Swedish paediatricians who are commissioned by RaddaBarnen to do a follow-up study in Kakuma in 1995. Olle Jepson and Anders Hjern (2006, 67) argue that the culturespecific socialization processes of young boys among Dinka “proves to be very efficient in coping with the stresses of flight and war” and 2 in congruence with the 1988-9 observations argue that levels of PTSD are dismissible.2 More recent surveys conducted among diverse populations inside South Sudan arrive at varying conclusions about the prevalence of PTSD in South Sudan. Nina Winkler (2010, 4) studied the mental health status of forty male and female ex-combatants and women associated with the SPLA in three reintegration centres in Juba, Torit and Aweil and concluded that although all participants had been exposed to traumatic events, she diagnosed only one individual (accounting for 2,5%) with PTSD. Ayazi et al. (2012) conducted research into socio-economic and trauma-related risk factors associated with PTSD, depression and PTSD-depression comorbidity in Greater Bahr el Ghazal amongst a population of 1200. The research found PTSD in 331 (28%) and depression in 75 (6,4%) of the study population. The researchers found that socioeconomic disadvantage and exposure to traumatic events increased the occurrence of both PTSD and PTSD-depression comorbidity and increased levels of psychological distress. Ayazi et al (2012, 2) emphasize “the influence of aggravated social and material conditions related to armed conflict”. Although none of the surveys are longitudinal, all assume an accumulative nature of trauma. In the period between October 2014 and April 2015, the South Sudan Law Society interviewed 1525 individuals in 11 locations across six of the ten states of South Sudan and Abyei to gain a 2 Although Jepson and Hjern are critical of the biomedical model of trauma, the research preidentified symptoms related to post-traumatic suffering: intrusive memories; mood and fears, and does not take into account that concepts of sadness and fear are highly subjective and contextual. It is important to note here that the authors describe ‘Dinka culture’ in highly archaic, static and homogeneous terms, openly referring to Dinka culture as “so exotic” (ibid., 79). The imagery of a singular and static ‘Dinka culture’ is false as wider forces of economic transformation, colonial and postcolonial rule, urbanization, civil war and conversion to Christianity and Islam significantly altered social relations and cultural practices. IJPS Justice and Peace Brief 01|2018 deeper understanding on perceptions of truth, justice, reconciliation and healing in South Sudan. The survey found that 41% of respondents endorsed symptoms consistent with a diagnosis of PTSD. The number of people who exhibit PTSD symptoms was higher amongst people who were displaced at the time of the survey and men (45%) showed more symptoms of PTSD than women (36%). A survey similar in nature was conducted in the Protection of Civilians (POC) site in Malakal in August 2015 and surveyed 1178 people. Fifty-three percent (48% male and 52% female) of respondents exhibit symptoms consistent with a diagnosis of PTSD. All these surveys operate from a universalising medical approach and use similar survey methods, like Harvard Trauma Questionnaire, MINI International Neuropsychiatric Interview, Hopkins Symptoms Check-List, etc., and reference to and build on each other. These instruments are all quantitative and close-ended in nature and use ‘yes’/’no’ questions and fixed severity scales (i.e. ‘not at all’, ‘a little’, ‘quite a bit’, ‘extremely’). The researchers uncritically presuppose a universal understanding of scales, perceptions of time and understandings of metaphysical concepts like ‘ability’, ‘energy’ and ‘emotional problems’. Researchers emphasize that these instruments have been designed or adapted to be used in a non-clinical setting and are universally recognized and validated transcultural instruments to screen for trauma in refugee and conflict-affected populations, but a comparative analysis of these different studies clearly shows that the measures innately confirm a causal connection between traumatic experiences and psychiatric symptoms like PTSD, depression and suicidality. We caution against the manners in which humanitarian organisations, researchers and international institutions “appropriate and strategically deploy aspects of the category of “trauma” (Lester 2013, 754). There exists a thin line between the pathologizing of suffering and the normalizing of psychological disorders, a process that can clearly be observed from the 3 initial and careful introduction of trauma to an almost unquestioning application. Concerns and expressions of distress are not homogeneous and universal, but are culturally and socially grounded. Even though PTSD symptoms are diagnosed, this does not mean that people react similarly to traumatic experiences or that these are relevant in the ways in which people give meaning to daily life experiences. A singular focus on trauma and PTSD symptoms ignores how people deal with insecure daily life conditions and continued exposure to violence. These studies thus are grounded in a particular Western nosologic framework that dominantly focuses on individual pathology and does not acknowledge that “situations are invariably constituted by intersubjectivity, social and economic conditions of possibility and constraints, and the shaping of cultural expectations of persons in relation to gender, mental and political status” (Jenkins 2015, 3). The focus of PTSD symptoms tends to be on past events; however, in a continuously insecure and fluctuant environment, people may be more preoccupied with immediate life conditions. Local Vocabularies on Suffering and Mental Health The Western biomedical model ignores complex differences in the interpretation of psychological symptoms and causal attributions. The adoption of a transnational concept, in this case the trauma concept, occurs simultaneously with a process of adaptation in which new ideas and meanings are framed and presented in terms of existing cultural norms, values and practices and transnational ideas are altered and transformed into something different but still called by the same name. Mental health is “not confined to a psychiatric vocabulary; it is embedded in everyday usage” (Fassin and Rechtman 2009, 9). Byron Good and Devon Hinton (2016, 5) propose to move away from the narrow view of PTSD to a broader view of ‘complex trauma’ that focuses on the “effects on lives in particular cultural settings and the implications for trauma treatment and trauma research in cross-cultural settings”. We propose a shift in focus from “categorical comparative universalisms of clinical diagnoses” to “cultural and local everyday particularisms” (Good 2013, 744), but at the same time we emphasize the need to be critical towards oversimplifying divisions between universal/particular, biomedical/cultural, neurological/behavioural and intrapsychic/intersubjective as in mental health notions and practices individual, interpersonal, local and translocal spheres overlap. Our empirical research shows that the overall majority of research participants have varying degrees of familiarity with the trauma concept and only one-quarter of the research participants were entirely unfamiliar with the concept and had never heard of the word trauma. This lack of familiarity was generally explained in reference to one’s educational and experiential background. People were commonly introduced to the concept in a humanitarian, educational or religious context, both inside South Sudan and in neighbouring countries. Most of the research participants with a minimal knowledge of the trauma concept were introduced to the concept after the outbreak of renewed violence in December 2013, which confirms the intensification of usage in a context of renewed violent conflict and humanitarian emergency relief. Generally, research participants establish a direct connection between trauma and violence, both on a personal and a more collective or national level. The trauma concept is used to describe a diverse set of experiences that are interrelated to violent conflict: domestic and sexual violence, poverty, unemployment and inability to meet normative societal expectations. JK3 speaks in a comprehensive voice when he states that: 3 IJPS Justice and Peace Brief 01|2018 Juba, 6 September 2016. 4 “In every corner here in South Sudan, people speak about fighting which means people have been traumatized by conflict. Not a single person is not traumatized because even those who run to the refuge they now think about shunuu, about fighting in South Sudan. Those in the government, they are now thinking about fighting. Those in the opposition, each and every person is now thinking about fighting, which means that every mile of South Sudan is about fighting, which means that they have been traumatized by this.” Research participants identified gendered and generational categories of traumatized people. Women and children are commonly described as more vulnerable in a situation of violent conflict and displacement and are believed to be more affected by trauma than men. For example, LC4 states: Our empirical data shows that across the different language groups a distinction is made between conceptual and descriptive translations of trauma. The conceptual translations largely liken trauma to madness and the descriptive translations are more conditional or symptomatic in character, referring to the situation that leads to trauma or describing a diverse set of physical, psychological and physiological symptoms. These symptomatic descriptions generally refer to a ‘confused’ or ‘destroyed’ mind. There exists a clear hierarchy between the two and the latter is considered to be more severe and permanent than the former. Both the terms confusion and destruction are also used to describe the broader situation of violent conflict in South Sudan. These gendered and generational understandings are informed by societal norms and dominant masculinities as in the instances men were described as traumatized it was not in reference to experiences with direct violence, but more in relation to the inability of men to fulfil dominant masculinities, like the provision of food and protection of family. These understandings build on societal ideas and expectations of how women and men are supposed to behave in the face of violence and destruction and although dominant masculinities across different communities in South Sudan are shaped variously, they often contain militaristic, patriarchal and hyper-masculine characteristics. No technical vocabulary exists for trauma in the various colloquial languages and although narrators generally translated trauma as madness, it is clearly understood by the majority of narrators that not all signs and acts of madness can be explained as trauma and trauma is seen as a lighter form of madness. Participants commonly discuss trauma as causing a change in thinking patterns and mind-set defined in terms of a shift from ‘normal’ to ‘abnormal’. This involves an interpretation of madness as ‘abnormality’ as well as a reference to the situation in the country and can be perceived as one of the ways in which people give meaning to conflict dynamics and precariousness and sometimes fail to comprehend the extremities of everyday life. SA5 defines trauma as “when anything bad happened to you it changes your thinking and other people can see you as you are not in yourself, also your thinking order will change when something bad happens to you (…) you get shocked and remain abnormal and cannot live a normal life.” In both Bari and Dinka the word confusion is derived from the word famine or drought (Bari: dyanugu; Dinka: arier), or more generically a situation of ‘absence’, which describes the consequences of a situation of loss, which seems as expandable as the understanding of trauma: 4 5 “I will say most people who are affected are children and women, because most time women know, with this struggle, very many struggles, with these very many conflicts, more people who lost their life are men in the struggle and then they leave women and children with nothing. So this one automatically accumulates a trauma against them, because they cannot afford anything. As well men, some few are affected, because if you cannot put food on the table, you find yourself running mad as the result. So, but most types people who are affected by trauma are women and children.” Terekeka, 6 August 2016. IJPS Justice and Peace Brief 01|2018 Juba, 20 September 2016. 5 dispossession of land, displacement, food insecurity and hunger, theft of or separation from property and personal belongings and violation on personal freedoms, but also more metaphysically to an absence of faith and dignity. This is in opposition to the emphasis of trauma as a condition in which there are too many thoughts, or more specifically too many bad thoughts, which refers to an unconstructive abundance. Coker (2002, 23) finds a similar focus on ‘thinking too much’ among South Sudanese refugees in Cairo and argues that it “was a very common exacerbating factor in illness, even if it was not seen to have directly caused the illness.” Trauma is generally understood to be situated in the head. In Bari this is explained as dyanguyy na kwe (confused head) or korju na kwe (spoiled/damaged head). In Nuer this is described as ram mi ca cere nyon (a person whose head is destroyed). In Dinka this is translated as riak-nhom (head damage) or arier-nhom (confusion of the head). The words kwe (Bari), cere (Nuer) nhom (Dinka) literally translate as head, but it is emphasized by the narrators that head refers to the mind and not the brain, for which there exist a separate terminology in all the colloquial IJPS Justice and Peace Brief 01|2018 languages6. This distinction is telling as both the mind and the brain are believed to be situated in the head, but the brain is something that can be ‘touched’ (local, indigenous versus scientific knowledge), whereas the mind is abstract, metaphysical. We carefully establish a connection here that needs to be explored in more depth to understandings in Acholi and Balanda (which are both from the Luo language family), where the word trauma is translated as jokjok7, translated both as gods (pl.) and madness. The reference carries multiple connotations: on the one hand trauma is perceived as something that is extraordinary and mysterious and inexplicable; on the other hand it refers to a person who is possessed by spirits and behaves in an uncontrollable manner. The cultural understanding of trauma as located in the mind and not the brain is in 6 The word for brain carries a similar root (nyit) in Nuer, Dinka, Acholi and Bari. Further research will have to be conducted to gain a deeper understanding of the etymological history of the word and its widespread usage. 7 Jok in Dinka is translated as evil spirit and in Nuer as disease. However, none of the Dinka and Nuer narrators established a clear connection between the concept of jok and the trauma concept. 6 opposition to Western medical explanations of trauma, which often speak exclusively about neurological processes. However, the majority of Nuer research participants – many of whom participated in longer or shorterterm trainings and workshops on trauma awareness and healing organised by international humanitarian organisations and religious institutions inside the Protection of Civilian (PoC) sites in Juba - shared an almost standardized definition of trauma with the student researchers that focuses on psychological processes. We emphasize that this confirms the global observation that the trauma concept gains traction in diverse social contexts as a result of humanitarian interventions as the lives of people inside the PoC are most intensely informed, even governed by humanitarian structures. Suggestions for a Research Agenda on Mental Health in South Sudan Our student-led research has shown that over the past decade many South Sudanese have internalized the trauma discourse and actively use it to express and characterize personal and societal experiences with violence, loss and death. The various meanings that are appointed to the trauma concept sometimes overlap with and often expand neuroscientific, biomedical classifications and existing phenomena and vocabularies like madness are used to speak about the psycho-social effects of violence and suffering. Intrapsychic, neurological approaches often overlook diverse and differing meanings and modes of the experiences of suffering and ways in which individual meaningmaking processes are tied into larger societal forces of possibility and constraint that inform and create collective and personal conditions of injury, disorder and mental health. In this Justice and Peace brief we emphasize the importance of moving beyond mental health studies that measure trauma and PTSD exposure and focus instead on the processes of adoption and adaptation of the trauma concept in diverse socio-cultural contexts and explore how this contributes to the creation of new vocabularies, understandings and experiences with afflictions and memory. We advocate for a more critical, interdisciplinary and relativistic investigation of the interconnection between violence, suffering and mental health that combines intrapsychic and intersubjective approaches. In South Sudan, an often essentialist, causal connection has been established between violence, suffering and mental health. Experiences with violence and suffering do not automatically translate into traumatisation and this narrow lens on South Sudan has contributed to a pathologization and homogenization of experiences with violent conflict, loss, death, displacement and food insecurity, ignoring socio-historical diversities. This student-led research project has many limitations and extensive long-term and multi-sited research needs to be conducted to better understand the interactions between (inter)national humanitarian organisations, religious institutions, community-based organisations and citizens in the area of mental health and psycho-social wellbeing. Further research needs to be conducted into existing mental health care infrastructures and treatment methods and practices in public hospitals and mental health support and services provided by humanitarian and church organisations as well as cultural beliefs and practices around mental illness among various social groups and how these different approaches and value systems interact with and influence each. This should involve doing research with the people afflicted by mental illness as well as with medical professionals, relatives and the wider socio-political environment into the biochemical, political, economic, spiritual and cultural dimensions of mental health (see Jenkins 2015, 7). References Ayazi, Touraj, Lars Lien, Arne H Eide, Majok Malek Ruom and Edvard Hauff. “What Are the Risk Factors for the Comorbidity of Posttraumatic Stress Disorder and Depression in a War-Affected IJPS Justice and Peace Brief 01|2018 Population? A Cross-Sectional Community Study in South Sudan.”BMC Psychiatry 12/75 (2012): 1-13. Breidlid, Ingrid Marie and Michael J. Arensen. ““Anyone Who Can Carry a Gun Can Go” The Role 7 of the White Army in the Current Conflict in South Sudan.” PRIO Papers 2014: 1-12. Online available at: https://www.prio.org/utility/DownloadFile.ashx?id =358&type=publicationfile. Breslau, Joshua. “Cultures of Trauma: Anthropological Views of Posttraumatic Stress Disorder in International Health.” Culture, Medicine and Psychiatry 28 (2004): 113-126. Coker, Elizabeth Marie. “Travelling Embodied Metaphors of Suffering Southern Sudanese Refugees in Cairo.” Medicine and Psychiatry 28 (2004): Pains”: among Culture, 15-39. Deng, David K., Belkys Lopez, Matthew Pritchard and Lauren C. Ng. Search for a New Beginning: Perceptions of Truth, Justice, Reconciliation and Healing in South Sudan. United Nations Development Programme, 2015. Online available at: http://www.ss.undp.org/content/dam/southsuda n/library/Rule%20of%20Law/Perception%20Surve y%20Report%20Transitional%20Justice%20Reconc iliation%20and%20Healing%20-.pdf. Deng, David K., Matthew F. Pritchard and Manasi Sharma. A War Within: Perceptions of Truth, Justice, Reconciliation and Healing in Malakal POC .South Sudan Law Society, 2015. Fassin, Didier and Richard Rechtman. The Empire of Trauma. An Inquiry into the Condition of Victimhood. Princeton and Oxford: Princeton University Press, 2009. Good, Byron and Devon Hinton. “Introduction. Culture, Trauma and PTSD.” In Culture and PTSD. Trauma in Global and Historical Perspective, edited by Devon E. Hinton and Byron J. Good. Pennsylvania: University of Pennsylvania Press, 2016: pp. 3-49. Jenkins, Janis H. Extraordinary Conditions. Cultures and Experience in Mental Illness. Oakland: University of California Press, 2015. Jeppsson, Olle and Anders Hjern.“Traumatic Stress in Context. A Study of Unaccompanied Minors from Southern Sudan.”In Forced Migration and Mental Health. Rethinking the Care of Refugees and Displaced Persons, edited by David Ingleby. Dordrecht: Springer, 2006: pp. 67-80. Karunakara, Unni Krishnan, Frank Neuner, Margarete Schauer, Kavita Sigh, Kenneth Hills, Thomas Elberts and Gilbert Burnha. “Traumatic Events and Symptoms of Post-traumatic Stress Disorder amongst Sudanese Nationals, Refugees and Ugandans in the West Nile. African Health Sciences 4/2 (2004):83-93. Neuner, Frank, Maggie Schauer, UnniKarunakara, Christine Klaschik, Christina Robert and Thomas Elbert.“Psychological Trauma and Evidence for Enhanced Vulnerability for Posttraumatic Stress Disorder through Previous Trauma among West Nile Refugees.BMC Psychiatry 4/34 (2004): 1-7. Roberts, Bayard and Eliaba Yona Damundu, Olivia Lomoro and Egbert Sondorp. “Post-conflict Mental Health Needs: A Cross-sectional Survey of Trauma, Depression and Associated Factors in Juba, Southern Sudan.” BMC Psychiatry9/7 (2009): 1-10. Winkler, Nina. “Psycho-social Intervention Needs among Ex-combatants in Southern Sudan.” Southern Sudan DDR Commission and Bonn International Center for Conversion, 2010. About this brief About the authors This Justice and Peace Brief is based primarily on oral history research conducted by a team of staff and student researchers of the Institute for Justice and Peace Studies (IJPS; formerly Institute for Applied Research and Community Outreach) between July and December 2016 in Juba, South Sudan. The research sought to gain deeper and more dynamic insights in societal understandings of and diverse vocabularies used to give meaning to and describe the mental health effects of violent conflict, displacement, loss and death on the lives of people. The research project was student-led and actively aimed to strengthen the research and analytical capacity of young South Sudanese graduates. The research was conducted by Albino Tongun, Jackson Zingbondo, Loes Lijnders, Rose Yangi, Rev. Dr. Stephen Ameyu, Stephen Gai, Vicky Amal and Zebedeo Malith. This Justice and Peace Brief has been prepared by Loes Lijnders. We warmly thank the Swiss Agency for Development Cooperation IJPS (SADC) for providing funding support for the Justice and Peace Brief 01|2018 student-led research project. About the Institute for Justice and Peace Studies The Catholic University of South Sudan (CUofSS) is a faith-based, private higher learning institution and provides bachelor and diploma programmes in the Faculty of Arts and Social Sciences in Juba and the Faculty of Agricultural and Environmental Science in Wau, South Sudan. The Institute for Justice and Peace Studies, established in 2017, is an interdisciplinary centre in the Catholic University and provides academic programmes, conducts research and engages in community outreach on a wide range of 8 topics related to social justice, non-violence and peacebuilding.