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 war’s conclusion. The situation was indicative of the state of the entire health sector. When UNMIL assumed authority in Liberia at the end of 2003, all that remained of the MOHSW was the crumbling edifice of a building on Capital Bypass Road in Monrovia, a gutted national infrastructure of clinics and hospitals, thousands of emigrated or displaced medical professionals, and a backlog of salaries that had not been paid in years. The ministry’s main assets—its health clinics—had been stripped of their wiring, roofs, benches, doors, and sinks, as well as all medications, equipment, and supplies. Humanitarian medical organizations sent staff and supplies to JFK Hospital to keep it running, and health care across the country was administered by a patchwork quilt of medical humanitarian NGOs. Even after UNMIL’s quick restoration of the MOHSW with a fresh coat of white paint with blue trim, generators, vehicles, and a few computers, the MOHSW still confronted a significant labor crisis. Its “human assets,” medical professionals, had found employment as “volunteers,” social workers, counselors, translators, logisticians, or educators with humanitarian NGOs. There were legal and administrative barriers to hiring new medical staff, and many Liberian health workers preferred to work for NGOs, where materials, medicines, salaries, and physical security were somewhat assured. This would have implications for the debates around the professionalization of mental health services in just a few years’ time.
Psychiatric care, like the rest of the medical sector, was in a state of collapse. The Katherine Mills Rehabilitation Institute had been completely destroyed during the war (see Figures 1–3) and transformed into a squatter settlement for 250 people. The WHO Mental Health Atlas noted in 2005 that Liberia lacked all of the following: epidemiological data, a mental health policy, a substance abuse policy, a national mental health program, mental health legislation, mental health financing, and mental health facilities. Serious mental illnesses were managed in alternative spheres like churches and mosques, among traditional healers, and within families and communities. Epilepsy and madness were explained with reference to witchcraft and sorcery by all of Liberia’s tribal and ethnic groups.
By 2003, trauma-healing activities had been under way in Liberia for nearly a decade, and Liberian NGO workers told me that mental health and psychosocial interventions were being widely questioned. Phalanxes of international experts again descended upon Monrovia to conduct short-term (four-day to two-week) trauma training sessions. Liberians noted that vast sums of money seemed to be spent on these trainings, and on the salaries of psychosocial workers who were purportedly trying to meet recruitment quotas. Intensive trauma counseling was giving way to more cost-effective “community-based ownership” models, or TOT approaches, which could shallowly capture a wide audience, and did not require long-term investments in treating serious mental illnesses or psychosocial disorders. Therefore, the flurry of activity around trauma-counseling TOT consultants and DDRR ex-combatant rehabilitation kept trauma-healing and psychosocial intervention locally relevant, while donors continued to share the sentiment that mental health was “not a priority.”
The biggest site of expenditure on mental health was in the DDRR process, where for approximately eighteen to twenty-four months, monies flowed freely. From the outset, UNMIL, the U.S. government, and the NTGL had committed rhetoric and financing to psychiatric assessment and psychosocial interventions for demobilizing combatants in the cantonment sites, to education programs, and to job retraining projects that they sponsored from 2003 to 2006 (see Richards 2005).
Despite the fact that international donors knew that the Liberian state could not possibly assume responsibility for mental health or psychiatric care, it left ambiguous the locus of authority for psychiatric interventions, trauma-healing programs, and psychosocial activities. Within the DDRR process, the WHO sought to have a supervisory role over the health—and the mental health—components of demobilization. It tried to recruit Dr. Grant, then known as “the Liberian Psychiatrist,” to participate in the WHO DDRR Project, and to lead mental illness diagnosis efforts among the more than one hundred thousand ex-combatants who were contained at the many dispersed cantonment sites for disarmament and demobilization. Although the WHO was quite keen to have a Liberian psychiatrist involved, Dr. Grant died just before DDRR, and his position was left empty. A WHO report commented,
In the initial agreement it was contemplated to have a total of six staffs, two national medical coordinators instead of one and a national psychiatrist specialist. For the first phase of the process we reviewed the question and agreed upon the need of just one national doctor, but for the mental health component it was a different situation. The director of the Monrovia Psychiatric Hospital was contacted by WHO to be in charge of the mental health part of the programme, but unfortunately passed away some days before the start of the DDRR process. It was impossible to find a reliable national candidate to do the work and finally, mid September, an international psychiatrist was engaged, but at that time the demobilization exercise was in a very advanced status and almost close to an end. This lack of a specialist could have biased our findings regarding mental diseases. (Larrauri 2004, 15)
Despite
