In 2014, Boko Haram gained international attention for its brutal attacks—including its abduction of hundreds of schoolgirls—in Northeast Nigeria. This attention, though, could not bring back the daughter of one woman, who was described to me by a primary health care provider who worked in the region. This mother had previously experienced “many traumatic events” including “losing seven of her children from childhood illnesses” and her husband two years earlier. Her daughter—her only child—represented “the only sense of hope she had left.” For this reason, when the daughter was abducted, “the woman felt a loss of the sense of what she was living for” and “concluded that the best thing for her to do was to take her life.” She is one of so many whose mental well-being was negatively affected by Boko Haram violence, a too often ignored component of the damage wrought by the conflict in Nigeria’s Northeast.
Indeed, while extensive literature has been written about the physical consequences of war, most visions of “holistic” peacebuilding overlook the often invisible mental costs created by war. People affected by conflict may witness traumatic events, be separated from their families, become victims or perpetrators of fighting, and be exposed to sexual violence. These experiences raise the risk of developing mental disorders such as Post-traumatic Stress Disorder (PTSD), anxiety, and depression. A systematic review by the WHO in 2019 estimated that more than one-in-five residents of conflict-affected countries have a mental disorder. In post-conflict societies, treatment of these disorders is rarely possible given the insufficient mental health infrastructure, exacerbated by the toll of armed conflict. Roberts and Fuhr estimate that more than 80 percent of conflict-affected people with mental disorders do not receive treatment.
Although many peacebuilding initiatives do not include a mental health component, Nigeria’s State Ministry of Health has worked closely with the International Organization for Migration (IOM), WHO, and local non-governmental organizations (NGOs) since 2015 to expand mental health and psychosocial support (MHPSS) in Northeast Nigeria, which has been affected by conflict with Boko Haram. This intervention includes deploying mobile teams of mental health specialists to hard-to-reach areas, training primary care providers in mental healthcare through the WHO’s mhGAP program, and referrals to the federal neuropsychiatric hospital for specialized services. Overall, more than 400,000 people have been reached by MHPSS programs in Northeast Nigeria as of 2019.
As Figure 1 shows, the fields of MHPSS and peacebuilding are intrinsically related. Conditions of violence create mental health disorders, but so too do mental health challenges breed violence. Tankink and Bubenzer find that mental health stresses make a return to conflict more likely as they fray the social fabric within communities, weaken opportunities for reconciliation and economic recovery, and increase the desire for revenge-seeking. It is thus imperative that mental health practitioners and peacebuilders respond to conflicts together to disrupt this reinforcing cycle of violence and mental health challenges.
The UN has hailed Northeast Nigeria as a success story in integrating mental health support with peacebuilding — a need that the UNDP has recognized as “essential for building sustainable peace.” How is this process actually going on the ground? How far has this integration gone and what barriers has it encountered?
These are the questions I explored in my research alongside Professor Syed Shabab Wahid, sponsored by the Laidlaw Foundation Fellowship. The study included in-depth qualitative interviews with a diverse range of stakeholders working in Northeast Nigeria (n = 13), including mental health specialists (n = 7), primary health care providers (n = 2), non-specialists trained in MHPSS (n = 1), and peacebuilders (n = 3). The results were analyzed via framework analysis, including qualitative coding. These results are preliminary as the study’s sample continues to expand.
Most respondents mentioned the importance of integrating the fields of MHPSS and peacebuilding in responding to the conflict in Northeast Nigeria. Nine respondents (69%) mentioned that the conflict in Northeast Nigeria had deteriorated social cohesion by breaking traditional bonds and social structures within the community due to abductions, physical and mental injury, the proliferation of widows, and men becoming combatants on either side of the conflict. These respondents argued that this breakdown in social cohesion had to be resolved via psychosocial work before peace processes could be successful. As one respondent, a 43-year-old peacebuilder, put it: “I don’t think that we can expect people to contribute sustainably to peacebuilding processes if we haven’t done some level of work on recovering from, accepting with, and preventing the past from disrupting the present. We carry legacies of anger, of hurt, and of mistrust which in turn erode our empathy and erode our willingness and our ability to understand others. Similarly, we can’t have people who have participated in MHPSS processes return and contribute to society if that society is damaged.”
Several respondents mentioned that, when mental health issues—particularly trauma—are left unresolved, they can result in a desire for “revenge” that feeds into more conflict. In particular, most respondents (77%) mentioned that the process of reintegrating ex-Boko Haram combatants was adding to mental health challenges, as communities find difficulty accepting the return of those that harmed them. As one mental health specialist told me: “Reintegration creates problems, because there are community members who have seen the same ex-combatants raping their wives, taking their wealth, or killing either a friend or sometimes even a brother, and plundering everything in the community. And then today, there is a government development partner outside saying that the same person that destroyed our means of life gets accepted into the community.”
On the other hand, respondents mentioned that the ex-combatant also commonly experiences mental health challenges, including the trauma and moral injury suffered on the battlefield where children who were abducted by the group may have been forced at gunpoint or “brainwashed” into committing violence against their community.
The respondents I interviewed described a range of efforts being made to integrate mental health and peacebuilding interventions in Northeast Nigeria. A few respondents discussed integrating MHPSS and peacebuilding by making “MHPSS the umbrella under which other concerns, such as protection, counter-trafficking, and GBV are part of as one unit.”
Several respondents described mental health programming provided directly to ex-combatants to help them process trauma and move forward as productive members of society, in turn aiding the construction of peace. Other programming is also being provided to community members including community sensitization, forgiveness, acceptance, and trauma counseling meant to help these communities process and accept reintegration processes.
The respondents I interviewed shared dozens of stories of the life-changing impact that these programs were having on communities affected by conflict. As one mental health specialist described to me: “The cycle of violence usually starts with trauma. And then the next stage is fantasies of revenge, where the person will begin talking about needing to attack the person who attacked them. And after this attack, the enemy becomes also traumatized and the cycle keeps going. So psychosocial peacebuilding will help break that cycle and make the person start thinking about the need to forgive.”
Another mental health specialist shared a story of working with eight ex-combatants and “teaching them they should have to take responsibility for their actions, and, having understood the kind of harm they have caused, there’s a need for them to also contribute their culture to whatever environment they find themselves in.” In the case of one ex-combatant the respondent worked with, “He still reaches out and calls me and tells me the progress he’s making in his life. And he is loved by the people in the community where he is, even though they do not know what he has done. But he worked closely with people, he helped a lot of people as he feels that helps him to pay restitution for what he has done in the past.”
However, barriers persist in integrating these fields. Four respondents discussed the lack of knowledge among peacebuilders and mental health practitioners about their respective fields, as well as the donors that fund their projects. As one peacebuilder described: “People have not been taught that we need to connect these two fields together. If you don’t know how to do psychosocial peacebuilding, and then you start talking about some components of psychosocial peacebuilding, donors will say ‘No, this is not what I want. I want you to do core peacebuilding activities for these communities.’” Another peacebuilder justified their organization not working on mental health issues in a very similar fashion, telling me: “I’m sure mental health certainly would come into this. But like I said, we were not involved on that side of things. We only work on the general peacebuilding context.”
Three respondents noted that peacebuilders often hold a misconception that MHPSS is focused on trauma, rather than the range of issues that MHPSS practitioners respond to. As one mental health specialist described to me: “Peacebuilders think that if you speak about what happened to you, you will be fine. This is the main misunderstanding as peacebuilders do not understand that MHPSS is much more than trauma counseling.” This lack of awareness is only compounded by the stigma around mental health, which one respondent noted made donors and practitioners in the peacebuilding community less interested in MHPSS programming.
Some peacebuilders, for example, argue that mental health must take a back seat to more pressing humanitarian concerns, which creates disputes over sequencing. One peacebuilder told me: “What people will say to us over and over again, is like, yes, we’re traumatized. Like, sure, we need to soak up psychosocial support. But we need to eat first. People need access to medicine, they need access to food, they need to feel safe in their communities. And if they don’t have that, they’re not going to be able to heal from this trauma.”
Ultimately, the respondents I spoke to were pessimistic about the actual degree that mental health programming and peacebuilding were being integrated in Northeast Nigeria, despite the pronouncements from institutions like the United Nations which have declared Northeast Nigeria to be a case study in the success of such integration. Many respondents noted that, even in organizations engaged in both peacebuilding and mental health, work in these fields still occurs largely separately. As one mental health specialist described: “I’m an active member of the Northeast Nigeria MHPSS working group. For the past three years, I’ve been very active attending monthly coordination meetings. But then you hardly hear about the issue of peacebuilding from these experts working in the field of MHPSS. So the target for them is, let’s do psychosocial support. But then I remind them, you can’t do psychosocial support alone where you don’t integrate peacebuilding into it because what brought about psychosocial issues is because there are conflicts. So honestly, mainstreaming mental health into peacebuilding is not something that has happened a lot.”
To turn this tide and better create sustainable peace, I came up with several recommendations for how mental health and peacebuilding practitioners can work together better in Northeast Nigeria.
- Co-creation workshops among mental health and peacebuilding practitioners in Northeast Nigeria should occur whereby both sets of practitioners explain to the other what they do, what they know about each other’s work, and what opportunities they see in integrating their work. These workshops have been run in Kenya, South Africa, and Zimbabwe by the Institute for Justice and Reconciliation, with successful results in helping practitioners better understand their respective work, a prerequisite to successfully working together.
- MHPSS should be “mainstreamed” within organizations and institutions whose peace-oriented programming does not include mental health components, and vice versa. Mental health indicators should be used as ancillary indicators to evaluate the success of peacebuilding programs and more psychosocial peacebuilding programs should be piloted and tested.
- Collaboration between peacebuilding and MHPSS organizations should occur between those that engage in combatant reintegration work. Longitudinal surveillance should occur in communities accepting reintegrated combatants to monitor for mental health symptoms and respond to them among both ex-combatants and community members.
- A dedicated section of each meeting of the Northeast Nigeria MHPSS working group should include a discussion of peacebuilding integration work and should be attended by peacebuilding practitioners.
“There can be no peace without peace of mind.”
Debates over sequencing are robust between the fields of MHPSS and peacebuilding. Peacebuilders argue that creating security is imperative to help people meet their basic needs of survival and stop more people from being traumatized in war. Mental health specialists, on the other hand, argue that mental scars, when left untreated, prevent successful reconciliation and themselves can spark more conflict through revenge-seeking behavior. Both fields are correct — and in that sense neither is. Neither mental health specialists nor peacebuilders alone can create sustainable peace in Northeast Nigeria, or elsewhere. If they are to achieve sustainable peace, mental health and peace interventions cannot exist on separate timescales, as separate programs, and within separate institutions. Mental health is not just a personal problem—it is a societal one affected by and continuing to shape its socio-political context. As both violence and mental health challenges mutually reinforce one another to create a cycle of violence, it will take an integrated approach to improve the physical and mental well-being of those affected by conflict. As one respondent told me, “There can be no peace without peace of mind.”
Benjamin Oestericher is a student at Georgetown’s School of Foreign Service studying African Regional Studies and International Development. He is currently a Laidlaw Scholar and an intern at the U.S. Department of State.
Author’s Note: This study is ongoing and continuing to expand. If you have feedback or feel your expertise could be valuable, please reach out. The author can be reached at blo16@georgetown.edu
