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

debt to the work of Bruno Latour, and to actor-network theorists (Callon 1991; Callon and Law 1997; Latour 2005; Law 1992; Law and Hussard 1999).

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

Figure 1. Katherine Mills Hospital. Photo by author.

       1994–2003: Postconflict Mental Health

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

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

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

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

      Both the WHO and the LWF/WS oriented their psychosocial education to “scale,” targeting communities and groups rather than individual mental health counseling or treatment. Both also espoused a “training-of-trainers” (TOT) model meant to promote the sustainable dissemination of psychosocial knowledge. In the TOT model, short-term topical training sessions were offered to Liberian participants, who were then encouraged to go into their communities as local trainers, or health educators, and share their findings about trauma and mental health. But the LWF/WS’s long-term presence in Liberia and its rapid shift from an expatriate staff to a local Liberian staff seemed to have the effect of “indigenizing” the program, giving it a quality of local ownership that WHO initiatives seemed to lack. The LWF/WS program repeated training sessions in communities, had a long-term relationship with communities, and often spent the night in those communities. In the quiet night hours, after the official end of the training day, trainers would provide individual counseling to community residents. They also ran “after-hours” women’s encounter sessions where women recounted experiences of rape, or of sending family members to war. Eventually the LWF/WS shifted its training materials’ emphasis on PTSD theory and basic counseling skills to the meaning of trauma, to local problems like drug addiction and “human brokenness,” to the meaning of violence and the war, and to the meaning of the postconflict period. WHO materials never followed suit and instead upheld the priorities set by international consultants and elite Liberian psychiatrists and psychologists, such as HIV/AIDS and conflict management (see Table 3). But even with the local sensitivity exhibited by LWF/WS trauma-healing activities, by the end of the war, communities and trainers alike were growing tired of talking about violence, rape, traumatic memory, instability, and poverty, while nothing ever seemed to change.

Table 3. LWF/WS and WHO Trauma-Training Manuals

LCL-LWF/WS Trauma Healing and Reconciliation Program Peace Building Training Handbook

Training Trainers Human Brokenness Understanding Liberian History: Highlights of the Various Periods The Meanings of Conflict and Violence The Meaning of Post-Conflict Dealing with Trauma Substance and Drug Abuse The World of Communication

Psychosocial Skills Training Manual (WHO and UNESCO)

Stress Management Handling of Drug and Alcohol Problems HIV/AIDS, STDs Trauma Counseling including: General Concepts of Counseling Confronting Sensitive Issues Learning about Stress and Trauma Conflicts and How to Manage Conflicts

      The end of the postconflict demobilization process (DDRR) in 1997 did not lead to peace in Liberia, but it did serve to justify massive humanitarian withdrawal. Consequently, many trauma-healing and DDRR projects “on the ground” closed shop, while a few, like LWF/WS, continued to function. As the war gradually expanded again between 2000 and 2003, trauma-healing and psychosocial assistance projects were provided to Liberians living in refugee camps in Guinea and Sierra Leone, while the interior of Liberia became a no-man’s-land for all but the most determined aid organizations.

      By 2003, for example, CVT had been operating a trauma-healing counseling program for four years in the Kissidougou, Guinea, refugee camp, which housed an estimated 81,000 refugees (most of whom were Liberians), and across Sierra Leone. In order to recruit participants into the screening process, approximately 20 Liberian CVT psychosocial agents (PSAs) and 120 volunteer peer counselors were individually responsible for recruiting approximately 25 Liberians per month for six- to ten-week counseling sessions, which would have totaled approximately 18,000 screened participants. Many more thousands of friends, cohabitants, or bystanders witnessed the semi-public screening process, which included verbal training in how to recognize PTSD, depression, anxiety, and suicidal thoughts.

      These numbers give a sense of the density of trauma-healing interventions for Liberian populations outside of Liberia, and the paucity of services available inside of Liberia, at the