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Do No Harm: Toward Contextually Appropriate Psychosocial Support in

International Emergencies Michael G. Wessells

Columbia University and Randolph-Macon College

In the aftermath of international emergencies caused by natural disasters or armed conflicts, strong needs exist for psychosocial support on a large scale. Psychologists have developed and applied frameworks and tools that have helped to alleviate suffering and promote well-being in emergency settings. Unfortunately, psychological tools and approaches are sometimes used in ways that cause unintended harm. In a spirit of prevention and wanting to support critical self-reflection, the author outlines key issues and widespread violations of the do no harm imperative in emergency contexts. Prominent issues include contextual insensitivity to issues such as security, humanitarian coordination, and the inappropriate use of various methods; the use of an individualistic orientation that does not fit the context and culture; an excessive focus on deficits and victimhood that can undermine

empowerment and resilience; the use of unsustainable, short-term approaches that breed dependency, create poorly trained psychosocial workers, and lack appropriate emphasis on prevention; and the imposition of outsider approaches. These and related problems can be avoided by the use of critical self-reflection, greater specificity in ethical guidance, a stronger evidence base for intervention, and improved methods of preparing international humanitarian psychologists.

Keywords: psychosocial support, emergencies, unintended harm, resilience, cultural insensitivity

Large-scale emergencies such as tsunamis and armed con- flicts create not only massive physical destruction but also an enormous toll of psychological and social suffering (Boothby, Strang, & Wessells, 2006; Cardozo, Talley, Bur- ton, & Crawford, 2004; de Jong, 2002; Marsella, Borne- mann, Ekblad, & Orley, 1994; Miller & Rasco, 2004; Mollica, Pole, Son, Murray, & Tor, 1997; Reyes & Jacobs, 2006; van der Kolk, McFarlane, & Weisaeth, 1996; Wilson & Drozdek, 2004) in the low- and middle-income countries where most disasters strike. Prominent sources of suffering include attack, losses of home and loved ones, displace- ment, family separation, gender-based violence, and expo- sure to myriad protection issues such as recruitment into armed groups and trafficking.

A decade ago, mental health and psychosocial supports in international emergencies were relegated to the humani- tarian ghetto and seen as things to be done after the “real” humanitarian work of saving lives had been completed. This has changed as public awareness of the aftermath of emergencies has increased, and psychosocial supports have become familiar fixtures in the humanitarian response to disasters. More than any other single event, the 2004 Asian tsunami brought home to people worldwide the enormity of the psychosocial needs that emergencies create.

The expanded awareness of the importance of psychoso- cial intervention has brought an expansion of psychosocial interventions. Many practitioners, myself included, regard this as a positive development, because there is increasing evidence of the efficacy of psychosocial interventions in addressing issues of trauma (e.g., Barbanel & Sternberg, 2006; Carll, 2007; Green et al., 2003), depression (Bolton et al., 2007), family separation (Hepburn, 2006), recruit- ment (Betancourt et al., 2008), and related issues and in promoting resilience and positive coping by survivors and communities (e.g., Barber, 2009).

At the same time, practitioners increasingly recognize that there are risks involved with psychosocial interven- tions that may lead to unintentional harm (Anderson, 1999; Inter-Agency Standing Committee [IASC], 2007; Wessells, 2008). Here is a small sampling of do no harm violations I have seen in various countries.

Editor’s Note Michael G. Wessells received the International Humanitar- ian Award. Award winners are invited to deliver an award address at the APA’s annual convention. A version of this award address was delivered at the 117th annual meeting, held August 6–9, 2009, in Toronto, Ontario, Canada. Arti- cles based on award addresses are reviewed, but they dif- fer from unsolicited articles in that they are expressions of the winners’ reflections on their work and their views of the field.

842 November 2009 ● American Psychologist

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In 1996 in Rwanda, orphans from the 1994 genocide were placed in small orphanages or centers, many of which were funded by Western groups, including churches, who wanted to provide care and protection for unaccompanied and separated children. An unfortunate and unanticipated consequence was that the centers contributed to family sep- aration, as mothers desperate to support their babies aban- doned the babies on the orphanages’ doorsteps.

In 1999 in Tirana, Albania, where camps filled with Kos- sovar survivors of Serb attacks, an American psychologist had set up a tent for counseling women survivors of rape. For a woman to have entered the tent would have identi- fied herself as a survivor of rape, which many families re- gard as a stain on family honor that must be rectified by killing the survivor.

In 2002 in rural Sierra Leone, international nongovern- mental organizations (NGOs) worked after the war to sup- port the reintegration of formerly recruited children. Unfor- tunately, most programs privileged former boy combatants, despite the fact that large numbers of girls had also been recruited (McKay & Mazurana, 2004; Wessells, 2006). This gender discrimination was itself a significant source of structural violence and psychosocial distress.

The longer one’s engagement in humanitarian work, the greater one’s appreciation of its complexity, the potential for harm, and the need to address a number of important issues. These include contextual insensitivity to the cul- tural, structural, and political aspects of emergency situa- tions; excessive focus on deficits such as mental health problems without sufficient attention to resilience and cop- ing; overreliance on individualistic approaches; power abuses such as the imposition of outsider approaches; and the provision of inadequate training and supervision for staff, among others.

It is an understatement to say that there is a shortage of easy answers to countless ethical questions. To obtain ethi- cal guidance, practitioners often turn to professional codes such as the American Psychological Association (APA) Ethical Principles of Psychologists and Code of Conduct (APA, 2002; hereafter referred to as the Code of Ethics). Although these codes do offer some useful guidance, they are typically written around general principles and seldom consider the specific, highly sensitive issues that arise in contexts of humanitarian emergencies. This lack of speci- ficity makes it very difficult to define what constitutes ethi- cal and appropriate practice in international emergencies.

There is also inadequate research and training. The pau- city of research on which interventions work in large-scale international emergencies (Batniji, Van Ommeren, & Sara- ceno, 2006; Betancourt & Williams, 2008; Wessells & van Ommeren, 2008) has enabled an “anything goes” atmo- sphere. This is exacerbated by a lack of appropriate train- ing. Many doctorate-level psychologists trained in North American and European universities lack the cultural, hu-

manitarian, and other competencies needed to do responsi- ble, contextually appropriate psychosocial work in large- scale emergencies. Because of these factors, it is not uncommon for psychosocial interventions in emergencies to violate the do no harm imperative that is a cornerstone of the principle of beneficence.

In this article, I identify some of the primary do no harm issues that have surfaced repeatedly in my global work responding to armed conflicts as well as natural di- sasters. I write not from a high moral ground of assuming “I would never cause harm!” but from a humbler, grounded perspective that recognizes that all interventions (and even one’s presence) in emergencies have unintended consequences, including negative ones. Because emergen- cies are fluid, potentially volatile, and riddled with uncer- tainties and complexities, it is relatively easy even for sea- soned practitioners to cause harm. Still, much harm can be avoided through awareness; appropriate preparation and ethical standards; and a critical, reflective stance. This arti- cle is written in the spirit of enabling the awareness and critical reflection needed to prevent harm. Admittedly, it does not provide exhaustive coverage of this essential topic.

An important caveat is that what counts as a harmful practice is in the eye of the beholder. Indeed, the identifi- cation of harmful practices and judgments about the bal- ance of positive or negative effects of particular practices reflects one’s values as well as technical considerations. The question Whose values matter most? is salient because the values of humanitarians often collide with those of the affected population. To manage this issue, I focus on fre- quently occurring practices that have been identified as problematic not only by Western psychologists but also by national psychosocial workers in diverse contexts. Al- though the emphasis here is on unintentional harm caused by U.S. psychologists, the key points apply to all psycholo- gists and people who conduct psychosocial work in emer- gency settings. Because many of these people are not psy- chologists but psychiatrists, social workers, or trained paraprofessionals, I speak broadly of the unintended harm caused by psychosocial workers.

Insensitivity to Emergency Contexts and Systems

In emergency settings, one often encounters well-meaning U.S. psychologists who have no experience in international emergencies, little understanding of the local culture or context, and no relationships with the agencies or people in the affected areas. Although the psychologists are nobly motivated by the feeling that “I just had to come and help,” this approach has been described as “disaster tour- ism” or “parachuting” rather than as professional humani- tarian response.

843November 2009 ● American Psychologist

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Parachuting