Is promoting war trauma such a good idea?

A well-known medical journal, The Lancet, recently published an important systematic review and meta-analysis of mental disorder estimates in conflict settings, advocating for the scaling up of mental health interventions in such contexts. However, there is an assumption that the introduction of such treatments has no significant impact, except from a therapeutic one, in the settings they have been imported to. The authors' research in post-conflict northern Uganda analyzed the social impact of mental health interventions addressing post-traumatic stress disorder (PTSD) and showed that promoting trauma has had considerable socio-economic ramifications on the wider society. The introduction of trauma narratives has created a market where some are able to thrive, but many deeply troubled individuals remain invisible. The authors found no social benefits from promoting trauma, and few positive effects for individuals. Arguments for urgently upscaling mental health interventions of the kinds highlighted by the review in The Lancet, and which the authors have observed on the ground, should be treated with caution.

A well-known medical journal, The Lancet, has recently published an important systematic review and metaanalysis of mental disorder estimates in conflict settings by Charlson et al. (2019). It will replace World Health Organization assessments that are more than a decade old, and the new data is set to find its way into various kinds of reports and articles, substantially informing international policy and practice (see e.g. The New Humanitarian 2019; ICMHPSCS 2019). According to these latest WHO data, 'more than one in five people (22·1%) in post-conflict settings has depression, anxiety disorder, post-traumatic stress disorder, bipolar disorder, or schizophrenia' (Charlson et al: 2). For many anthropologists, the assumptions underpinning the endeavour to categorize and count war-affected people in these ways are deeply problematic, and potentially harmful (Mylan et al. 2019). For many anthropologists, the assumptions underpinning the endeavour to count the traumatized in war zones are deeply problematic, and potentially harmful (Mylan et al. 2019).
However, anthropological antipathy should not be overstated. Some academic anthropologists are more open to using internationalized psychiatric labels than others, and people with an undergraduate or postgraduate training in anthropology may work with agencies running therapy projects or related psychosocial support schemes. Is this anthropological openness to dominant mental health paradigms a positive step? We suggest it is not.

Anthropology and classifications of trauma
Particularly since Allan Young's groundbreaking work, the possible psychological consequences of exposure to violence in war zones have been the site of anthropological interest and critique. Young's discussion of the 'invention' of post-traumatic stress disorder (PTSD) as an aspect of the rehabilitation of American veterans after the Vietnam War located the clinical diagnosis in a broader critique around the social construction, cultural boundedness and cross-cultural validity of Western psychiatric categories (Young 1997). Most anthropologists, and some therapists influenced by their work, have tended to build on Young's insights, arguing that the idea of PTSD relies on understandings of personhood, suffering and recovery in particular populations, and that this kind of discourse on trauma and trauma treatment simply does not make sense outside of a particular cultural and moral framework (Kienzler 2008;Parker 1996aParker , 1996bSummerfield 2004Summerfield , 2012. While it may be that human beings exhibit comparable responses to extreme events, it is hard to discern exactly what those are, and much is experienced in very specific ways in different social groups in different places (Fig. 1).
Concerns have also been raised about the misplaced and superficial medicalization of suffering that the diagnosis of PTSD often facilitates, pathologizing entire populations, and causing 'a reframing of the understandable suffering of war as a technical problem to which shortterm technical solutions like counselling are applicable' (Summerfield 1999: 149). Such critiques have been incorporated into discussions around psychosocial and traumafocused interventions as new forms of 'international therapeutic governance' (Pupavac 2001(Pupavac , 2004, a means of control by which humanitarian actors (acting on behalf of 'Western' interests) seek to manage global social risk. This process of homogenization and pathologization can also be ultimately dehumanizing and depoliticizing.
The debate, for a long time polarized around the opposite positions of PTSD-oriented psychiatrists and anthropologists, arguing respectively for and against the cross-cultural application of PTSD, has taken a new turn in recent years. Some anthropologists are 'no longer sitting outside the To a large extent, this approach accepts the fact that, despite trenchant criticism -and not just by anthropologists -PTSD has evolved over the years, being redefined in successive versions of the Diagnostic and statistical manual of mental disorders -DSM (the handbook used in much of the Western world as a guide to the diagnosis of mental disorder), and shows no signs of being set aside. Indeed, the use of PTSD has become entrenched in a range of contexts, including legal proceedings, whereby military personnel in the UK and USA have secured compensation.

CHARITY ATUKUNDA
Perhaps it is therefore strategically sensible to work with PTSD and other psychiatric concepts, and help make them more nuanced. Such an approach may be helpful in highlighting the plight of suffering people, and possibly better interventions could emerge. But there are obvious risks. When anthropologists compromise, the result is sometimes compromised anthropology, and probably even those anthropologists willing to work with the PTSD label, or who contributed to revisions that have been made to the DSM in an effort to take into account cultural variation (APA 2013), will be unimpressed by Charlson et al.'s (2019) systematic review and meta-analysis.
The basic dilemmas faced by those wanting to emphasize the poor mental health of those caught up in wars or dealing with their aftermath have not gone away. It is impossible to aggregate data with any certainty, because there is no consensus about the relevant information to collect or the means of collecting it. It is neither known what therapies work at a population level, nor what evidence is needed to formulate suitable interventions. Both continue to be debated by practitioners themselves (see e.g. Bangpan et al. 2016;Summerfield 2008).
Moreover, the lack of independent assessment about the effects of various existing programmes has become integral to the continued roll-out of projects. The stated intention is purportedly to improve mental well-being, but there is rarely any attempt to find out what actually happens to those at the receiving end -including if they are alive, or have been re-recruited into militia, or are prone to violent acts.
As a consequence, Charlson et al.'s review is essentially about raising the profile of mental health in war zones, rather than providing a better overview. A range of studies, using different methods, are evoked strategically to claim that PTSD and war trauma in general are much worse than has previously been assessed. Strategies that go beyond clinical approaches are mentioned in passing, and it is acknowledged that diagnostic classifications of mental disorders assume universality in unhelpful ways. Nevertheless, Charlson et al. prioritize projects imbued with externally generated preconceptions as the way forward, proposing that scalable mental health interventions of this type should be urgently implemented. It is a contradictory position, which sets aside counterproductive consequences.

War trauma in northern Uganda
Our research in northern Uganda has analyzed the social impact of mental health interventions addressing PTSD and the social ramifications of introducing trauma discourses and conceptions of suffering based on Euro-American notions of the 'traumatized individual'. The research took place in the wake of a 20-year war between the government and the Lord's Resistance Army (LRA) -a rebel group which abducted over 50,000 people, about half of whom were children, forcing many to become soldiers or, in the case of young girls, 'wives' to the commanders (Allen & Vlassenroot 2010).
A common narrative has vaguely described the population as being collectively traumatized, while specific projects have targeted groups who are expected to manifest a range of symptoms or behaviours. Interventions range from counselling, mostly delivered by untrained local staff, to various poorly monitored psychological therapies and the distribution of psychiatric drugs, usually without prescription by qualified professionals.
Promoting externally defined conceptions of war trauma in northern Uganda has had considerable socioeconomic ramifications on returnees and wider society. While people are obviously deeply affected by traumatic experiences, externally introduced conceptions rely on a Western cultural and moral approach to extreme suffering, ringing immediately familiar to Euro-American ears and accordingly conveying a specific image of an emergency and its victims. Narratives of victimhood that strongly resonate with such Western 'trauma discourse' (Argenti-Pillen 2000) have become a form of currency in the region (Edmonson 2005). Their frequent appropriation and heavy marketization by NGOs (non-governmental organizations) and charities seeking to justify their opera- tions has created social hierarchies with serious impacts on people's lives and opportunities. As the possibility of receiving support heavily depends on individual narratives fitting donor-backed conceptions, those who can capitalize on their own narratives of suffering (sometimes moulded with the stories of others for strategic purposes), gain access to benefits and social leverage, becoming unlikely winners in a post-conflict setting where rebuilding lives is very challenging. , we have found a disparity in access to the largely material benefits associated with trauma narratives. Our work shows a substantial cohort of those who achieved command positions in the LRA or the status of senior wives have strategically adopted preferred modes of describing experiences, and thereby secured better livelihoods, including skills training and school fees.

MELISSA PARKER
Specifically, this means that they speak about their experiences in ways that fit trauma paradigms expected by aidfunded projects. Their accounts are often openly refined and shaped in peer support meetings so that the 'right' kinds of things are emphasized (Fig. 2). Those in the group have usually spent long periods of time with the LRA and almost invariably live in urban locations. Their lives are not easy, and they may well remain profoundly troubled by the lives they led with the LRA, but they are unlikely to be openly stigmatized by neighbours and rarely report affliction by cen, a form of spiritual affliction associated with those who have been in contact with violence and death.
In contrast, most of those returning from the LRA give accounts that are often more nuanced, and do not necessarily follow anticipated trauma narratives, thereby making them less interesting to trauma advocates. They are acquiescent and adhere to social norms, desperate to move on with their lives and not to be treated differently. Yet, we found many of them are deeply troubled. They are much more likely to suffer acutely from stigmatization and cen, often experiencing dire and traumatic suffering many years after their return. The disparity in opportunities to capitalize on internationally conceptualized trauma narratives to secure resources and practical assistance often results in their marginalization and social isolation. Less able or willing to craft their story to fit the ideas of NGOs and therapists, and now living far from the towns, they remain, therefore, largely invisible to such well-meaning actors.

Future mental health interventions
Arguments for urgently upscaling mental health interventions of the kinds highlighted by the review in The Lancet, and which we have observed on the ground, should be treated with caution. Anthropological engagement with universal trauma discourse and therapeutic pathways seems to have had no significant effect on what is being promoted so vigorously as best practice and the model for future trajectories of interventions in war zones and postconflict regions (Fig. 3). On the contrary, evoking anthropological contributions that work within the hegemonic paradigms largely serves to reinforce existing agendas. Thus, The Lancet review alludes to unhelpful aspects of assuming the universality of diagnoses and treatment as a way of ticking a box, while asserting an urgent need for rapid upscaling of current arrangements.
Our research suggests that instead there is an urgent need for humanitarians and clinical practitioners working in this arena to critically reflect on normative assumptions, and to adequately engage with understanding the lived realities and livelihoods of the people they seek to assist. We have found no social benefits from promoting internationallygenerated (and debated) classifications of war trauma, and few positive effects for individuals. Where positive effects occur, they are likely to be in terms of livelihood support. In practice, we find that current externally supported approaches to mental health systematically elicit the symptoms of affliction they purport to address, and may actually exacerbate problems. l