Self-help or silenced voices? An ethnographically informed warning
Authors: Costanza Torre
Journal: The Lancet Global Health (2020)

Wietse Tol and colleagues' study1Tol WA Leku MR Lakin DP et al.(2020). Guided self-help to reduce psychological distress in South Sudanese female refugees in Uganda: a cluster randomised trial.Lancet Glob Health. 2020; 8: e254-e263Summary Full Text Full Text PDF PubMed Scopus (84) Google Scholar in The Lancet Global Health describes the benefits of Self-Help Plus, a transdiagnostic psychological intervention aimed at stress reduction in humanitarian settings. Based on a randomised controlled trial in a refugee settlement in northern Uganda, their findings are impressive and benefit from extensive research. However, my ongoing, in-depth ethnographic research during the past 12 months in Palabek refugee settlement, northern Uganda, has identified crucial aspects that the study overlooks. In the psychosocial and socioeconomic context of South Sudanese refugees in northern Uganda, these factors should be taken into serious consideration. Self-Help Plus is a multimedia guided intervention, based largely on a pre-recorded audio track that guides beneficiaries through exercises based on Acceptance and Commitment Therapy (eg, mindfulness and relaxation exercises).2Epping-Jordan JE Harris R Brown FL et al.Self-Help Plus (SH+): a new WHO stress management package.World Psychiatry. 2016; 15: 295Crossref PubMed Scopus (52) Google Scholar Changes to the structure (eg, interventions from participants) are actively discouraged. The one-way nature of this approach is deeply problematic. In Uganda, scarcity and corruption-related mismanagement of UN funds often translate into scarcity of food and unfulfilled basic needs,3Green A Uganda went from being a model of refugee response to a cautionary tale.https://www.worldpoliticsreview.com/insights/26946/with-its-open-door-policy-toward-refugees-uganda-has-gone-from-model-to-cautionary-taleDate: Dec 10, 2018Date accessed: January 31, 2020Google Scholar generating deep insecurity and feelings of powerlessness that South Sudanese refugees fleeing a brutal war have to navigate daily. My ethnographic analysis shows that in this context, mental health interventions (eg, didactic counselling and cognitive behavioural treatments) have become outlets for beneficiaries to voice the very real problems that they are experiencing in daily life in the settlement. Most frequently, these are issues concerning scarcity of food, ineffective and inconsistent medical care at the health facilities, an absence of financial support to afford basic needs that fall outside of humanitarian aid (eg, soap and basic hygiene products or school supplies for children), and security concerns related to threatening living conditions in the settlement (including but not limited to domestic, sexual, and gender-based violence). Heavily scripted interventions like Self-Help Plus risk exacerbating the feeling of voicelessness and powerlessness that refugees are so accustomed to, silencing one of the few channels that people employ in an attempt to be seen and heard. Such interventions also risk shutting down the deeper political backdrop to their suffering. Furthermore, our analysis reveals that stand-alone psychosocial support programmes are often interpreted by beneficiaries as active disengagement by humanitarian actors from issues and concerns that the refugees have clearly expressed to them. It must be better acknowledged that, in the face of the severe unfulfillment of basic needs, psychosocial interventions should meaningfully engage with refugees' concerns, not only by avoiding silencing them, but also by encouraging effective two-way communication that is embedded within a robust, interagency referral system. I declare no competing interests. Guided self-help to reduce psychological distress in South Sudanese female refugees in Uganda: a cluster randomised trialSelf-Help Plus is an innovative, facilitator-guided, group-based self-help intervention that can be rapidly deployed to large numbers of participants, and resulted in meaningful reductions in psychological distress at 3 months among South Sudanese female refugees. Full-Text PDF Open AccessSelf-help or silenced voices? An ethnographically informed warning – Authors' replyWe thank Costanza Torre for her observations. In our Article,1 we described the results of a facilitated, group-based, guided self-help intervention to reduce psychological distress among female South Sudanese refugees in Rhino Camp settlement, northern Uganda. Torre's response is based on ethnographic doctoral fieldwork in a different refugee settlement in northern Uganda. Although we appreciate her insights, we think that some of her comments might be premature. Full-Text PDF Open Access