building sustainable peace through an integrated approach ......building sustainable peace through...

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Tankink&Bubenzer

Building sustainable peacethrough an integrated approach topeacebuilding and mental healthand psychosocial support:a literature review

MarianTankink & Friederike Bubenzer

Key implications for practice� The literature shows that integrat-

ing the ¢elds of peacebuilding andmental health and psychosocialsupport is currently only donepiecemeal

� Knowledge and tools in both ¢eldsshould be integrated

� There is a need for a theoreticalmodel that bridges peacebuildingand mental health and psychosocialsupport to inform and guide futureresearch and practice

The contribution of the ¢elds of mental health and

psychosocial support and peacebuilding is critical

to the repair of societies a¡ected by war and violent

con£ict. Despite some advances in bringing the two

¢elds closer together, the evidence base for the out-

comesand impact ofan integrated approach included

both mental health and psychosocial support and

peacebuilding is still very thin.The hypothesis for

this literature review was that a combined approach

would enhance the knowledge base and, therefore,

foster the prospect of sustainable peace.The litera-

ture reviewed indicates thatwhile there is an increas-

ing awareness of the need to bring some of the

knowledge and tools traditionally belonging to the

¢eld of mental health and psychosocial support into

peacebuilding interventions (and vice versa), this

is not yet practiced in a way that is fully integrated

from the outset or is holistic on a systemic level.This

study highlights the need for the development of a

theoretical model that bridges both ¢elds as a

foundation for future research and practice.

Keywords: con£ict, mental health, peace-building, post con£ict, psychosocial support,sustainable peace, violence

IntroductionIt is well documented that war and con£icthave drastic, long lasting e¡ects on commu-nities. Further, in the aftermath of war andcon£ict, the causes of interpersonal con£ictmight still exist andmayhave evenworsenedas a result of violence during the con£ict. A

ht © War Trauma Foundation. Unautho

return of the violence is also often likely tooccur in post con£ict countries where peoplehave witnessed and experienced large scaleviolence, destruction, displacement and per-sonal loss. A cursory overview of the last 35years shows that approximately 80% of thecountries globally that have emerged fromcon£ict return to violence in the years after.Most of these countries have not implement-ed holistic nor sustainable justice andreconciliation processes, which address theroot causes and impact of violence.1

Anecdotal evidence shows that organisa-tions and institutions working towards postcon£ict social transformation ^ be they inthe realm of peacebuilding (PB) or mentalhealth and psychosocial support (MHPSS) ^

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Building sustainable peace through an integrated approach to peacebuilding and mental health and psychosocial

support: a literature review, Intervention 2017, Volume 15, Number 3, Page 199 - 214

do not yet fully recognise this need, nor dothey structure their programmes in a waythat contributes to the long term psycho-social welfare of the a¡ected community orwider social context (Bubenzer, van derWalt, & Tankink,2017).To get a clear picture of developments relat-ing to solidifying the relationship betweenPB and MHPSS in (post) con£ict settings,the Institute of Justice and Reconciliationin CapeTown andWarTrauma Foundationin Amsterdam conducted a literature reviewin search of evidence that integratingMHPSS and PB approaches contributes tobuilding sustainable peace. While theauthors realise that when implementinginterventions, it is di⁄cult to predict sustain-ability, the authors believe that furtherresearch on the lasting e¡ects of implement-ing an integrated approach (evidence based)might generate more ‘proven tools’.To develop such comprehensive and sustain-able interventions and strategic partner-ships, those working in both ¢elds have tolearn from existing research and practi-tioners working within post war contexts.As such, this literature review addresses thefollowing question: what are the de¢ning

characteristics of the documented approaches which

integrate MHPSS and PB? In asking this ques-tion, there was also an interest to know if inthe underlying theoretical foundations thatunderpin existing work in this realm and inthe answer, do the ¢elds of PB and MHPSSbene¢t from such integration? This papercontains the most important ¢ndings inresponse (for more details see Tankink,Bubenzer, & van derWalt, 2017).

MethodologyFromAugust 2016 toMarch 2017, the authorsand two research assistants conducted a sys-tematic review of international literaturedescribing interventions or theoretical rea-soning on integrated MHPSS and PBapproaches.The hypothesis was that a com-bined approachwould enhance the prospect

ht © War Trauma Foundation. Unautho200

of sustainable peace. The systematic litera-ture review was supplemented with addi-tional literature found and receivedliterature suggested by colleagues. Thereview of academic journal based sourceswas supplemented with knowledge pro-duced by practitioners and nongovernmen-tal organisations (NGOs), and solicited ‘greyliterature’ (NGO reports, policy briefs andother documents); all of which met theinclusion criteria, detailed below.The inclusion criteria for the review were:that both concepts MHPSS and PB werereferenced; that the articles contributed tothe overall research question underlyingthe literature review; that the articles werepublished in the last 24 years (since the1992 Agenda for Peace2); and written in theEnglish language. For the purpose of thisreview, only articles were included, neitherbooks nor theses were incorporated,although the authors acknowledge thatthere are important books and theses thataddress this topic.Relevant scienti¢c literature was identi¢edby searching structured bibliographic sour-ces, including: PsycInfo (Ovid), Ovid Med-line, Evidence Based Medicine ReviewsFull Text Multi¢le Database Guide (Ovid),ACPJournalClub (ACP), CochraneCentralRegister of Controlled Trials (CCTR),Cochrane Database of Systematic Reviews(COCH), Cochrane Methodology RegisterDatabase (CMR), Database of Abstracts ofReviews of E¡ects (DARE), HealthTechnol-ogy Assessment Database (HTA), NationalHealth Service Economic EvaluationDatabase (NHSEED), PILOTS: PublishedInternational Literature On TraumaticStress, World Health Organization’s(WHO’s) Institutional Repository for Infor-mation Sharing, Social Science ResearchNetwork (SSRN), United Nations Biblio-graphic Information System (UNBISNET),COMPASS Knowledge BASE (opsic), andGoogle scholar.For the grey literature search, the authorsconducted searches with the relevant

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Table 1. Search terminology usedKey searchterm

1. MHPSS/community 2. PB/Justice 3. Approaches 4. Context

Symptoms 1.1MHPSS, mentalhealth, psychosocial

2.1Peacebuilding 3.1Intervention,support, program

4.1Con£ict,organisedviolence

1.2 Communities,families

2.2 Restorativejustice,human rights

3.2 E¡ectiveness 4.2 Genocide

1.3 Resilience,coping

2.3 Socialchange

3.3 Evidence(evaluation,reviews,trials, etc.)

4.3 Peace phase

1.4 Arts-based formsof interventions

2.4 Forgiveness 4.4 War-a¡ectedpopulation, gender,groups, age groups

1.5 Local capacity1.6. (Intergenerational)

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Tankink&Bubenzer

concepts through relevant humanitariannetworks and Google and directly visitedthe websites and downloaded documents ofNGOs known to the team and suggestedby other researchers and practitioners inboth ¢elds.The search strategy used to ¢nd these con-cepts (see Table 1) and the variations wasthrough the following structure: (1.1 OR 1.2OR 1.3 OR 1.4 OR 1.5 OR 1.6) AND (2.1OR 2.2 OR 2.3 OR 2.4) AND (3.1 OR 3.2OR 3.3) AND (4.1OR 4.2 OR 4.3 OR 4.4)

Screening and selectionThe search identi¢ed a total of 1373 items,with 341duplicates, that represented a bodyof literature of 1032 articles (see Figure 1).Abstracts of all 1032 articles and 19 add-itional articles were reviewed for relevanceby one or more of the reviewers, which iden-ti¢ed 104 papers as possibly meeting theinclusion criteria. The selected articleswere then reviewed by another member ofthe team. In cases where discussion ensuedabout the applicability of an article to thestudy, the authors jointly decided to includeor exclude the paper. Full versions of thesearticles were obtained, the detailed reviewof which led to 73 (marked with � in the


reference list) of the studies being con¢rmedas meeting the inclusion criteria. Theadditional articles were not included in theoriginal search, but were suggested by col-leagues as very relevant (marked with ˇ).Additionally, a total of 79 ‘grey’ documents(marked with 8) were identi¢ed, which hadthe same inclusion criteria as the scienti¢cliterature. The body of the literature thatprovides the basis for this review, therefore,was comprised of a total of 108 documents,45 identi¢ed through formal bibliographicsearch (and 26 additional journals), and 36identi¢ed through recommended websitesof the relevant NGOs in MHPSS and PB.The complete list of articles and grey docu-ments reviewed for this study can be foundat www.ijr.org.za/.

FindingsUnderlying theoretical foundationsAlthough a number of theoretical founda-tions were identi¢ed from the literaturereviewed, several articles do not overtly referto a theoretical framework.The frameworksthat were found can almost all be groupedunder a holistic or socio-ecological para-digm. The socio-ecological framework isbased on the notion that violence and


http://www.ijr.org.za/

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1373records

identified

19additional

records

79NGO

documentsidentified

73 studies & 36NGO documents

included

79selected

for abstractreview

79selected for

full textreview

123selected for full

text review

1032selected

for abstractreview

341duplicatesexcluded

928excludedupon full

text review

50excluded

43excluded

Figure 1: Overview of selection of papers during review process.



con£ict are explained as the cause and out-come of multiple factors that interact at fourdi¡erent levels: the individual level, therelational level, the community level andthe societal level or, in more general terms,the micro-, meso-, exo- and macro levels(Bronfenbrenner, 2005)All authors recognised that an individual issituated within social, political, economic,historical, spiritual and cultural contextsand that this broader environment, in whichindividuals operate and interact, should betaken into account when working towardsenhancing the psychosocial wellbeing ofindividuals and communities, and towardssustainable peace. Almost all frameworksused are community based and emphasisethe interpersonal and social linkagesbetween individual health and wellbeingand community wellbeing and rehabilit-ation. Their entry point is at the level ofcommunity, with a focus on individualsand families within that community. Adopt-ing this ecological model enables a more


holistic, socio-ecological approach that sup-ports an investment on how di¡erent levels,dimensions and systems of temporal trajec-tories in£uence each other to produce aninteractive, dynamic (dys)functional whole(King, 2014; Somasundaram & Sivayokan,2013) According to the literature reviewed,a holistic approach, which integratesMHPSS and PB, needs to be utilised fromthe very beginning of an intervention, inorder to bring about sustainable changeand to accommodate the multiplicity andcomplexityof factors that are in constant £uxwith one another in society.Very few articles and only one NGO com-bined MHPSS and PB aims into asingular approach (Anckerman, Domin-guez, Kjaerulf, &Mikkelsen, 2005; Berliner,Dominguez, Kjaerulf, & Mikkelsen, 2006;De Jong, 2010; Gutlove & Thompson, 2004;Hart, 2012; Hart & Colo, 2014; InternationalAssociation for Human Values (IAHV),2016a, 2016b, 2016c; Sliep & Gilbert, 2006;Spitzer & Twikirize, 2014).The vast majority


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of papers used their own ¢eld as a startingpoint and tried to add elements from theother ¢eld, e.g. in the MHPSS ¢eld ele-ments of reconciliation and transformativejustice were often mentioned, and in thePB ¢eld trauma healing was a frequentreference.It is beyond the scope of this paper to outlineall approaches found in the literature. How-ever, so that thismightbe useful as a resourcefor further reading, the articles found thatare connected with speci¢c methodologiesarementionedbelow.While recognising thatarticles or interventions can be positionedunder more than one approach, the mainapproaches and frameworks in the articleswere: the Psychosocial Community Basedapproaches (Gutlove & Thompson, 2004;Mendelo¡, 2009; Nqweni, 2002; Richters,Rutayisire, Sewimfura, & Ngendahayo,2010; Spitzer & Twikirize, 2014; Staub, 2013;Staub, Pearlman, Gubin, & Hagengimana,2005; Sveaass & Castillo, 2000); CommunityBased Restorative Transitional Justice(Cilliers, Dube, & Siddiqi, 2016; Mart|¤ n-Beristain, Pa¤ ez, Rime¤ , & Kanyangara,2010; Park, 2010); Constructivist Self Devel-opment Theory (Pearlman, 2013); the Com-munity Psychology Framework (Lykes,Terre Blanche, & Hamber, 2003); Arts BasedCommunity Frameworks (Sliep & Meyer-Weitz, 2003; Zelizer, 2003); PsychosocialPeacebuilding Theory (Hart & Colo, 2014;King, 2014; Weder, Garc|¤ a-Nieto, & Can-neti-Nisim, 2010); the Personal Transforma-tion Model (Hamber & Gallagher, 2014);the Therapeutic Justice Model (Pupavac,2004); thework of the Liberation PsychologyMovement (Laplante, 2007); the Transper-sonal Resilience model (Machinga & Fried-man, 2013; Park, 2010); the ConceptualFramework of Health and Transitional Jus-tice (Mendelo¡, 2009; Pham, Weinstein, &Longman, 2004); the Social Capital Theory(Lee, Rondon, & McCullough, 2006;Somasundaram & Sivayokan, 2013); thePublic Health Approach (de Jong, 2010;Christensen & Edward, 2015); and the


Adaptation and Development After Perse-cution and Trauma Framework (ADAPTframework) (LeTouze, Silove, & Zwi, 2005).

Characteristics of approachesintegrating MHPSS and PBAt the very heart of the work done byMHPSS workers and those working on PBin post con£ict communities is the sameoverarching goal: to enable people a¡ectedby con£ict to realise their full potential andto be able to lead productive and peacefullives (Christensen & Edward, 2015; Gutlove& Thompson, 2004). Most authors con-cluded that PB andMHPSSmustbe broughttogether to ensure e¡ective social changeand transformation. This requires an in-depth, structured analysis process. Thebasis is that reconciliation and trustbuilding is dependent upon the building ofrelationships between parties that wereinvolved in the con£ict. Like many others,Solomon and Lavi (2005) argue that thereis a complex relationship between politicalviolence, posttraumatic stress disorder(PTSD) and attitudes towards peace. Theysuggest combining mental health andpeace education interventions to break theoften, overlooked cycle of violence and trau-matisation. Important common elementsthat were found in the literature arepresented below.

De¢ning peace and violence How keyconcepts, such as peace and violence, arede¢ned fundamentally shapes the way PBand MHPSS projects are developed andimplemented. Chopra (2013, p. 4) notes thatviolence can be both direct and indirect.Direct violence is the physical or psycho-logical harm caused by individuals, whileindirect violence refers ‘to the systemic social

injustices, oppression and discrimination through

existing legal, political, cultural, social and

economic structures’. The drivers of violenceinclude ‘psychosocial distress, isolation and mar-

ginalisation’. Recognising that the indirect


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e¡ects of violence can be psychosocial,de¢nes violence through not only its cause,but also its e¡ects.Within the grey literature, it was evident thatthe de¢nition of peace, violence and con£icta¡ected the implementation of NGO’s prac-tices and approaches. Acknowledging thatpeace is more than simply the cessation ofhostilities, the complex nature of violenceand con£ict requires PB approaches to begrounded in multidisciplinary practices thatinclude psychosocial principles, politicaland institutional, and community initiatives(Alliance for Peacebuilding, 2012; CareInternational UK, 2012; Chopra, 2013;Fischer, 2004; International Alert, 2013,2016; International Association for HumanValues (IAHV), 2016c; Oxfam, 2015;Sonpar, 2008; War Child Holland, 2007a,2007b; Women Peace Building Initiative,2015).

Human security In the aftermath of con-£ict, meeting people’s basic physiologicaland psychological needs ought to be a prior-ity. Perceived and real threats of violence,created during and after con£ict, generatesuspicion and deepen mistrust andmay con-tinue to exist in the undercurrents betweenindividuals and within communities. How-ever, given resource constraints, as well asthe uncoordinated and imbalanced rush toprovide services to war ravaged communi-ties, the sequencing and prioritisation ofthe provision of basic services tends tobe skewed.The growing concept of human security pro-vides a framework within which to organisepost con£ict humanitarian interventions.Gutlove andThompson (2004: p.142) explainthat ‘the need for safety underlies all other aspectsof the healing process.’ Sighting a study evaluat-ing psychosocial assistance programmesduring and after the Croatian and Bosnianwars in former Yugoslavia, they note that‘the most important bene¢t these programmes couldprovide was a safe space, psychologically and phys-

ically, in which people could rebuild their previous


social contacts and make new contacts. The safe

space was more important than any particular

type of psychological intervention or therapy’. Notprioritising human security means thatpeople continue to experience perceivedand real fear.

The centrality of narrative in MH andPB approaches The literature reviewedrefers to a wide variety of narrativeapproaches that are used for multiple pur-poses, such as to legitimatise sources ofknowledge, understanding, truth tellingand for therapeutic uses. Therapeutic usesof narrative approaches include: emotionalcatharsis; the creation of linguistic represen-tation; habituating anxiety through expo-sure; empathic witnessing of injustice;developing explanatory accounts; and iden-tifying the value or purpose of narrative inadversity (Cole, 2010, p. 652). As Cole (2010,p.651) states:‘it is through stories that we form our-

selves in the aftermath of life-altering experiences’.Narrative is used to tell the experience ofan event in terms of the emotional andexistential sense making (ibid). However,Mendelo¡ (2009) and Cilliers et al. (2016)found that the relationship between truthtelling, psychological healing and PB isdubious. hile the truth and reconciliationcommission model is based on the assump-tion that positive e¡ects are generated forpeople participating in truth telling pro-cesses, for many people the e¡ects are nega-tive in that they have the potential ofopening psychological wounds that canresult in increased depression, anxiety, orPTSD. Cilliers et al. (2016, p.787) ‘suggest thatpolicy-makers need to restructure reconciliation

processes in ways that reduce their negative psycho-

logical costs while retaining their positive societal

bene¢ts.’

Restoring trust and rebuilding inter-communal relationships Rebuildingtrust between victims, perpetrators andbystanders after con£ict is fundamental tobuilding long-termpeaceand reconciliation.


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Peacebuilding and psychosocial supportinterventions in con£ict a¡ected communi-ties aim to reconstruct social networks andrebuild trusting relationships over andaboveadvocating for the physical requirements ofsurvival. The Alliance for Peacebuilding(2012) adds spirituality as a social, cognitiveand emotional resource necessary for over-coming trauma, fear and bigotry. Spiritual-ity teaches empathy, compassion andpromotes the synergy of connecting mindand heart. The organisation states thatempathymaximises social-emotional intelli-gence, helping people feel a greater sense ofconnection and promoting social ties thatsupport peace. The cornerstone of IAHV’speace work is formed out of multiple dimen-sions that includes the personal, whichspeci¢cally targets mindsets, attitudes,behaviours, as well as the wellbeing of com-munities and individuals. Their work isimplemented at multiple societal levels,including the physical, existential andcogni-tive. (IAHV, 2016a; 2016b).

Health as societal and ecologicalrather than individual and medicalAnckerman et al. (2005, p.144) expand ontheWHO (2014) de¢nition of health by stat-ing that it constitutes ‘a good level of functioningin the actual context, including being recognised

and accepted as a member of the community’.Writ-ing about the PB and reconciliation divi-dends of integrated health services inBurundi, Christensen and Edward (2015,p.41) site a number of interview extracts con-ducted with con£ict a¡ected individualswho participated in their study, one of whichclearly points to the need to see health associetal and ecological; ‘if you are healthy, youcanfocuson other things. . .yourchildren, yourwork,making a good home, being a good neighbour. . .’and ‘when children are sick, they are crying, yelling,uncomfortable. And the family has no way to have

a conversation at home. It becomes hardship’. Berli-ner et al. explain that ‘health is understood in awide and positive way as the dimension of relation-

ships between individuals and groups, and not only


as an individual condition of absence of disease’(2006, p.3).It is important to acknowledge the nature of,and di¡erence between, individual and col-lective experiences of trauma. A number ofapproaches sited in the literature reviewedin this study target their work at individualsand communities alike, acknowledging thatthose who are particularly a¡ected (andare experiencingadvanced PTSD symptomsor severe mental disorders) require one-on-one work, while the majority of peoplewill bene¢t from approaches that aim torebuild intra-group relations through trustbuilding, recreating a sense of belongingand storytelling.Zelizer (2008, p. 3) states that ‘statisticsrelated to PTSD should be taken with a sig-ni¢cant degree of caution. It is di⁄cult toobtain baseline data, and western imposedinstruments and frameworks may not ade-quately capture the diverse range of individ-ual and community responses that canresult from exposure to trauma’. This isechoed byWessels (2008, p.2) who explainsthat ‘the limits of the trauma paradigm have become

increasingly conspicuous. Withering conceptual

assaults have identi¢ed numerous limits ofa medical

model and its problematic western assumptions

and foci on pathology, symptoms, and curative, ther-

apeutic processes’. He adds that ‘the trauma para-digm decontextualises human su¡ering by reducing

it to individual terms, when many of the greatest

sources of su¡ering are collective and are grounded

in a socio-historic context of human rights viola-

tions’.Wessels proposes a localised, re£ectiveprocess aimed developing a holistic concep-tualisation of psychosocial wellbeing thatcentres on risk, resilience and protective fac-tors, and that highlight the importance ofcommunity mobilisation, culture, socialecologies and social justice.

Health as an entry point to social andpolitical transformation Traditionally,health has been seen as a means to increasethe health conditions of community mem-bers and has not been linked to social and


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political transformation by the political eliteand leaders. However, using health as theentry point for interventions holds compara-tive advantages, such as health not beingperceived as a political discipline, it cane¡ectively be used as a conduit to addressingsocial andpolitical issues within the commu-nity. The health community has a uniqueand crucial role to play in promoting ahealthy society, not only by mending thephysical and psychological wounds of indi-viduals, but also by rebuilding structuresfor public health care and creating bridgesfor community reconstruction and socialreconciliation.Berliner et al. (2006) and Anckerman et al.(2005, p.144) state that for their projects‘health is used as the entry point for psychosocial

and physical attention to communities highly

a¡ected by organised violence and torture’. Berlineret al. go on to state that ‘the programme’s aimof increasing the overall functioning capacities of

the participants in the community links the signi¢-

cance of ‘health’ to social and political transform-

ation, meaning that the need for physical and

psychosocial treatment may well be addressed

through the engagement in processesof reconciliation,

empowerment and development’ (2006, p.3).

Gender Several authors stress the impor-tance of taking gender issues into account,but few documents overtly link gender andgender relations in post con£ict settings toMHPSS and PB. This might be a resultof the search terms used for this study. Mostliterature ongender focused onwomen, theirsocial position and violence perpetratedagainst them.Con£ict often changes the role and positionof women in society (Pankhurst, 2003). Inmany con£ict settings, where women andgirls are forced to‘serve’ the troops (Theidon,2009, p. 19), and in post con£ict settingswhere sexual violence is common, socialroles have become militarised. As men jointhe war e¡ort, women take over the role ofmen, changes which tend to be experiencedby women as moments of liberation from

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old social orders and restrictions. Researchconducted inpost con£ict countries indicatesthat sexual violence after peace agreementscontinues, or worsens. The economic, cul-tural and geopolitical changes resultingfrom con£ict ‘as well as gender inequalities ineducation, social and economic domains as a result

of the con£ict have evidently disempowered women

and girls with a profound impact on their sexual

and reproductive health/rights’ (John-Langba,John-Langba, & Rogers, 2013, p.63).Dijkman, Bijleveld, & Verwimp (2014)explain that in Burundi, sexual violencehas not decreased after the war.The authorsassume that this is a result of the degradationof moral standards and values, and thenormalisation of violence, often in combina-tion with poverty, lack of schooling oremployment, vengeance in neighbourhoods,psychological problems and challenges withthe integration of ex-combatants.Currently, more attention is paid to mascu-linity and the position of men. Slegh, Barkerand Levtov (2014), found that in the Demo-cratic Republic of Congo, a deeply patri-archal society with a high degree of genderinequality, exposure to con£ict and con£ictrelated stress were key drivers of men’s useof perpetrating intimate partner violence.By analysing men’s responses to stress andtrauma, they found that strategies for copingwith loss andtraumaaregendered;mentendto copewith stress throughviolentbehaviouror substance abuse as a way of redressingtheir sense of emasculation, victimisationand vulnerability.

DiscussionRebuilding a society after war and violentcon£ict is complex and many (often unfore-seen) factors are at play at di¡erent levels,at di¡erent periods of time and with di¡er-ent groups or populations, in di¡erent sec-tors of society. Given the nascence of this¢eld, working with an approach thataddresses everything is unrealistic. How-ever, an in-depth assessment of a given

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situation should give an overall view and itshould be clear how a piecemeal approach¢ts in this whole and is related to otherapproaches.Also, is important to acknowledge that therecognition that MHPSS and PB shouldbe linked, or even integrated with oneanother forboth disciplines to jointly achievesustainable social transformation goals inpost con£ict societies, is a relatively newone. The reviewed literature indicates thatwhile there is an increasing awareness ofthe need to bring some of the knowledgeand tools traditionally belonging to the ¢eldof MHPSS into PB interventions (and viceversa), this is not yet practiced in a way thatis fully integrative from the outset or that isholistic at a systemic level. It is not yet clearwhat the best way to do this would be andcurrent research does not provide cleardirection.While the majority of articles reviewed forthis study do share an underlying assump-tion that societies can change and that suc-cessful transformation is based on aholistic, socio-ecological approach whichrecognises that individuals exist in anuanced social, political, economic, spirit-ual, cultural and psychological context, theevidence base for the outcomes and impactof an integrated approach of MHPSS andPB is limited. The vast majority of articlesreviewed are integrative only in a piecemealway, appending or inserting useful elementsfrom the other discipline at one or maybetwo speci¢c points in the project cycle, ratherthan throughout.Few of the studies contain a model, whichintegrates both disciplines completely fromthe outset and inboth avertical and horizon-tal way, so that fundamental values, goalsand objectives of MHPSS and PB are inter-woven. Such amodel is needed for coordina-tion and linking di¡erent players in the¢eld, to guide integrated implementationof interventions and to develop a body ofevidence that proves enhanced impact andreduces risk factors for sustainability.


The centrality of narrative was found to becommon to MHPSS and PB approaches;many authors referenced narrative basedapproaches (individual and collective) asessential for addressing the psychosocialimpact of con£ict in post con£ict societies.Restoring trustandrebuilding intercommu-nal relationships was a further cross cuttingtheme identi¢ed as fundamental to long-term peace and reconciliation. It wasremarkable that only IAHV paid attentionto nonverbal interventions, such as nonver-bal stress management exercises, althoughincreased attention to the positive e¡ects ofthe concept of mindfulness was visible inthe literature reviewed.Another important ¢nding of this study thatis relevant for workers in the ¢eld of PB, isthat health is considered to be more than justthe absence of disease. Rather, it is a state ofbeing in which one’s physical, emotional andcontextual existence are of such a quality thata healthy, productive and socially engaged lifecan be lived. This is synonymous with thenotion of positive peace, advanced by thepeacebuilding ¢eldwhich, in turn, emphasisesthe many synergies that support the aims ofMHPSSand PB practitioners.The concentricnature of peace and health is aptly expressedby one key informant interviewee cited byChristensen&Edward (2015: p.39):

‘When there is no health in the household

first, there won’t be peace, everybody will be

stressed out and worried, you won’t be able to

work, you won’t be able to eat, and then that

will create tension . . .In the community it is the same thing: if a

neighbour is sick all the time, people can say

their neighbour poisoned them and there can

be jealousies and blame. . .It is the same thing for the country: if there is

no health, there is no production, and there is

stress between people . . . It is just what I seeevery day’.

What this literature study highlights, is thatexisting research needs to be consolidated ^


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with a particular focus on developing asound theoretical framework and imple-mentation model ^ before an evidencebase is built that is grounded within a newframework andmodel.

Limitations: missing topics inthe reviewed literatureA few topics were identi¢ed by the authorsas missing from the literature reviewed forthis article. These topics were identi¢ed,in part, as a result of anecdotal evidenceemerging from contemporary discussionsthe authors have been part of throughoutthis project and as a result of feedbackgathered during an experts meeting held inCapeTown in May 2017, where the prelimi-nary ¢ndings of this study were presentedfor veri¢cation and feedback. These topicsare brie£y discussed below.

Intergenerational transmission ofviolence and traumaThe reviewed literature pays little attentionto the intergenerational transmission ofviolence and trauma, although we knowthat a growingamount of literature is payingattention to this. It might be a result of thesearch terms used in this literature review.Richters (2015) and Creary and Byrne(2014) found that the transmission of traumaand its impact on the role of identity fromone generation to the next are importantelements that contribute to the establishmentof peace. The authors see a link betweenpsychological factors and con£ict and peace.Therefore, they express the importance ofincorporating attention to psychosocial ele-ments in peace e¡orts. Marginalised andvictimised communities tend to cling to nar-ratives that have been passed down acrossgenerations, internalising these, often, nega-tive narrative historical traumas as a formof seeking belonging and a shared identity.

ChildrenChildren was not a search term included atthe outset of this study. As a result, references


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to children and how they feature vis-a' -visMHPSS and PB was mostly absent in theliterature (except in reports by NGOs witha focus on children). Ardila-Rey, Killen, &Brenick (2009) did research on how violencein£uences the way children in Colombiaresolve con£icts and disagreements. Usuallychildren from di¡erent cultures evaluatemoral transgressions, such as hitting andthe denial of resources, as wrong due to thenegative intrinsic consequences a¡ectinganother person (ibid, p.182). The pervasiveviolence in Colombia has negatively a¡ectedchildren’s moral development. Extremelystressful conditions in£uence how childrenthere evaluate moral transgressions andhow they view provocation and retaliation.The other novel and more encouraging¢ndings were that almost all children,whether displaced or not displaced, consid-ered reconciliation possible.

New developments: neuroscience,endocrinology and epigeneticsNeuroscience is a promising and rapidlygrowing interdisciplinary scienti¢c ¢eld thatprovides insight into brain activity andhuman behaviour. Fitzdu¡ (2016) addressesthe question ‘what does neuroscience have to o¡erpeacebuilders?’ Only in recent years havescientists been able to show the e¡ect ofviolence on people’s brain processes in rela-tion to experience and behaviour. Althoughmost of our approaches and interventionsare based on rational thoughts, our behav-iour is largely driven by emotions (Burrell& Barsalou, 2015; Fitzdu¡, 2016). Uncon-scious processes are the engines for emotions,especially fear, and are largely regulated bythe amygdala, a part in our brain that alsodeals with emotions and memories. Pitman,Shin, & Rauch (2001) show changes in theamygdala (part of the brain) among peoplewho have experienced violence.Taylor (2016) concludes that support formen-tal health in these processes is important,because depressive symptoms negatively


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in£uence the coping with past exposure topolitical violence and social trust. Social,economic and political factors feed into amacro contextual system that contributes toa cycle of violence and mental health disor-ders (Sonpar, 2008).The brain development of children is ham-pered by experiences of violence. (Perry,2003).Teicher (2000; 2002) discovered signif-icant brainwave abnormalities in 72% ofpatients (inwestern countries) with a historyof early trauma. At the endocrinologicallevel, it has been noticed that trauma andsevere stress cause high levels of the hormonecortisol, that is related to PTSD, and thisnegatively in£uences other hormones suchas oxytocin that is needed for a sense ofbelonging and connectedness to a group, itis the ‘glue’ between people (Fitzdu¡, 2016).Furthermore, it seems that whenwe encoun-ter people or groups that we consider to be‘others’, ‘our brain often switches o¡ the empathic

neurons and actively resists any emotional contact

with the perceived group’ (ibid, p.3). People areunaware that their brains have automaticsystems that in£uence behaviour such asprejudice, stereotyping and dehumanisation(Burrell & Barsalou, 2015).Thus, for sustain-able change, the emotional and rational partof peoples’ brains also need to be included.Another new development is the ¢eld ofepigenetics, the study of inheritable changesin gene expression. Here, scientists have dis-covered that although one’s DNA structuremay remain the same, the environment inwhich people operate in£uences the activityof the genes, selectively turning them on oro¡.These active or passive genes are passedon to the next generation. How peoples’traumatic experiences in£uence and changethe gene structure of their children andgrandchildren, is not yet clear.3 Walters,Mohammed, Evans-Campbell, Beltra¤ n,Chae, & Duran (2011) state that historicaltrauma is embodied in the next generations.Kellerman (2011, p.7) explains that childrenhave to carry the load of their parents, butthat childrenalso seemtohave thepossibility


to ‘better control of [their] inner ‘‘switch board’’’.They might be able to choose to switch o¡the terrible history of their parents. If so, thismight give a more positive view to theepigenetic burden.

Other limitations of the studySeveral other limitations must also be noted.The study began as a systematic review.However, despite the broad range of searchterms used, we soon noticed that someimportant articles had been excluded.Extending the range of terms would havegenerated a number of hits that would havebeen beyond our capacity to review. Forexample, with the research term ‘intergenera-tional trauma’, we might have found morearticles if we searched for ‘intergenerationaltransmission of trauma’.To remedy this, and since the objectivewas togenerate a solid overview, we included sug-gestions of relevant articles passed on to usby colleagues. This review does not coverthe full published body of literature. Thiswas also due to language restrictions (onlyEnglish articles were reviewed) and becausebooks and theses were excluded due tocapacity and resource constraints.

ConclusionThe hypothesis for this literature review wasthat a combined approach of PB andMHPSS would enhance sustainable peace.The literature illustrates that how key con-cepts such as peace and violence are de¢nedfundamentally shapes the way PB andMHPSS projects are developed and imple-mented. In understanding the foundationalaims of each discipline, the review identi¢eda key commonality: that both MHPSS andPB are required to restore and develophealthy human relationships and that both¢elds have the same overarching goal toenable people a¡ected by con£ict to realisetheir full potential and to be able to live pro-ductive and peaceful lives.The reviewed lit-erature also indicates that, while there is an


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increasing awareness of the need to bringsome of the knowledge and tools tradition-ally belonging to the ¢eld of MHPSS intoPB interventions (and vice versa), this isnot yet practiced in a way that is fully inte-grative from the outset or that is holistic ata systemic level.Using health as the entry point for interven-tions holds comparative advantages; ashealth is not perceived as a politically sensi-tive discipline it can e¡ectively be used asa ¢rst step towards addressing social andpolitical issues in a community. At the sametime authors caution against a limitation ofmental health to a‘trauma paradigm’, its prob-lematic western assumptions and foci onpathology, symptoms and curative, thera-peutic processes. Using this paradigm runsthe risk of decontextualising human su¡er-ing by reducing it to individual terms, whenmany of the greatest sources of su¡eringare collective and are grounded in a socio-historic context of human rights violations.It is important to recognise the need todevelop a context speci¢c and localised lan-guage and practice to adequately addressthe nuances of local needs, taking intoaccount gender issues (both for women andmen), the transmission of intergenerationaltrauma and considering that human secu-rity underlies all other aspects of psychoso-cial peace building (PSPB) processes. PSPBis the new approach to PB which integrates,from the outset, an understanding and aresponsiveness to the psychosocial impactof con£ict on individuals, communities andsociety at large.Despite some advances in bringing thetwo ¢elds closer together, the evidencebase for the outcomes and impact of anintegrated approach of MHPSS and PB issmall, and more research needs to be doneto explore new ways of bringing the twodisciplines closer together. The study high-lights the need for the development of atheoretical model that bridges MHPSS andPB as a foundation for future research andpractice.

ght © War Trauma Foundation. Unauth210

AcknowledgementsWe are very grateful to Sarah van derWalt andAlfa Gasani who did the majority of the work ofreviewing the literature for this review. Theirdedication and enthusiasm was amazing andinspiring. Unfortunately, they were not able toparticipate in the writing of this article, but it islargely based on their work.

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1 Personal communicationwith a board memberof the Institute forJustice and Reconciliation.2 Peacebuilding ¢rst started becoming a familiarconcept following United Nations SecretaryGeneral Boutros Boutros-Ghali’s 1992 reportAgenda for Peace (United Nations [UN], 1992)which de¢ned PB as an ‘action to identify and supportstructures which will strengthen and solidify peace and

avoid relapse into con£ict’.3 See ‘The Ghosts in our Genes’, a Science Documen-tary hosted by Barbara Flynn and published bythe BBC, broadcast as part of BBCHorizon seriesin 2005.

MarianTankink, PhD, is medical anthropolo-

gist, consultant for War Trauma Foundation,

and Editor in Chief of Intervention.

email: [email protected]

Friederike Bubenzer is Senior Project Leader,

Great Horn Desk, Justice and Reconciliation

in Africa Programme, Institute forJustice and

Reconciliation

DOI:10.1097/WTF.0000000000000165


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mailto:[email protected]

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