“Think Positive, Save a Life”? Resilience and Mental Health Interventions as Political Abandonment in a Refugee Settlement in Northern Uganda

ABSTRACT

This article investigates the entanglements of resilience-based refugee policies and mental health interventions in the refugee settlement of Palabek, northern Uganda. I argue that both resilience refugee policies and mental health humanitarian interventions stem from a neoliberal logic which shifts responsibility onto individuals for their psychological and economic wellbeing. I show that there are direct links between chronic food insecurity and rates of mental illness among South Sudanese refugees in Palabek settlement. By individualising social suffering, mental health discourses and interventions mask the failures of humanitarian assistance in Uganda. As such, they justify and enable the political abandonment of refugees.

Introduction

The concept of resilience began to gain traction in the humanitarian field in the 1980s, and in recent years has become a catch-all term to tackle a vast array of issues in crisis response (Ilcan and Rygiel 2015). A notion with an apparently benign ring to it, resilience is defined by the UN Refugee Agency (hereafter UNHCR) as ‘the ability of individuals, households, communities, national institutions and systems to prevent, absorb, and recover from shocks, while continuing to function and adapt in a way that supports long-term prospects for sustainable development, peace in security, and the attainment of human rights’ (UNHCR 2017, p. 3).

In particular, refugee aid has come to be constructed as aimed at ‘building resilience’ in displaced communities (Hilhorst 2018), giving a new spin to humanitarianism’s old adage of ‘helping refugees help themselves’. This approach is particularly prominent in Uganda, a country with a long history of hosting and generating refugees, which currently hosts 1.5 million forcibly displaced people. Since 2016 this figure includes just under a million South Sudanese refugees, who reside in the most recently established settlements, concentrated in the north of the country (UNHCR 2022a). In Uganda, recent policy shifts have established notions of resilience and self-reliance as core pillars of refugee management. Resilience discourses strongly emphasise the role of individual responsibility, constructing people as autonomous economic actors who are capable of self-government for their survival and well-being.

Duffield (2015) has argued that resilience-focused policies lay the ground for states’ abandonment of citizens. In refugee situations, where scarcity of resources and complex sociocultural and geopolitical circumstances sharpen pre-existing social inequalities, resilience discourses transfer responsibility for refugees’ wellbeing upon themselves. In so doing, however, they divert responsibility away from states and non-governmental institutions (Krause and Schmidt 2020). This legitimises withdrawal of support at a time in which funding availability for refugee emergencies is at an historical low, thus substantiating Hilhorst’s warning that resilience humanitarianism may turn into a ‘politics of abandonment’ (2018, p. 10) of refugees.

However, resilience-thinking is not the only trend to have recently emerged in humanitarian thinking and policy. Over the past twenty years, a rise in the attention for the psychological burden of humanitarian crises has resulted in mental health and psychosocial support interventions (MHPSS) to become an ever-present component of emergency response. This phenomenon has gradually and deeply transformed the way in which humanitarian crises are understood and tackled (Pupavac 2001). In both academic and policy discourses, the needs of crisis-affected populations have come to be increasingly understood in psychological terms, with diagnoses of post-traumatic stress disorder, depression and anxiety dominating popular imageries of emergency (Summerfield 1999, Fassin and Rechtman 2009).

In this article, based on long-term ethnographic fieldwork in the refugee settlement of Palabek, northern Uganda, I analyse mental health interventions in the context of the Ugandan ‘resilience and self-reliance’ humanitarian landscape from a social justice perspective. Scholars have extensively examined both the resilience and the mental health turn in humanitarianism; however, these shifts are rarely discussed as related to one another, and little is known about their discursive and pragmatic intersections. Mental health interventions are generally understood as clinically relevant and politically neutral; their political significance, however, emerges from an analysis of the contexts – both geopolitical and humanitarian – in which they are implemented.

As argued by Fassin (2011), while the various actors and institutions involved in the design and delivery of humanitarian aid will inevitably respond to emergencies according to their competences, their operations are shaped by the same hegemonic discourses. With this consideration in mind, I begin by discussing the resilience and mental health turn in humanitarianism as stemming from the same dominant ideas of neoliberal governmentality. Secondly, I outline the situation of food insecurity in Palabek settlement, and show that here resilience-based humanitarianism enables the structural and systemic abandonment of refugees. Finally, I argue that mental health interventions and policy narratives in Palabek individualise and medicalise refugees’ socio-economic distress, significantly contributing to a wider politics of abandonment of refugees across Uganda.

Context and Methods

This article is based on material gathered during fourteen months of ethnographic fieldwork, which I conducted in Palabek refugee settlement, northern Uganda. The settlement is the most recently established in the country, and is now home to over 76,000 South Sudanese refugees (Government of Uganda and UNHCR 2022), with the Acholi-speaking refugee population representing the most numerous group. Palabek is located in a remote area of Lamwo District, one of the least developed in Uganda, where up to 75 per cent of people are estimated to live in poverty (World Bank 2018), and which still suffers heavy social and economic consequences of a brutal civil conflict that devasted northern Uganda between 1986 and 2006. Between October 2018 and March 2020, I lived in Palabek settlement with a family of Acholi-speaking South Sudanese refugees. Interested in the encounter between Western understandings of psychological distress and the lived reality of displacement as experienced by refugees, I followed the work of several non-governmental organisations (NGOs) working in the field of mental health in Palabek and offering a range of different interventions.

Living in the settlement, which most humanitarian and government workers would leave before sunset, allowed me to position myself as separate from the refugee management apparatus. This gave me the chance to build relationships and engage in conversations that would not have happened otherwise, and to closely witness how resilience and self-reliance policies are experienced by refugees in their daily life and how they can affect psychological wellbeing. In particular, the findings that inform this article stem from over two hundred hours of participant and non-participant observation which I conducted at group therapy sessions and at the local mental health clinic in Palabek refugee settlement. I was also allowed to analyse the local mental health clinic’s records, to better study the processes through which diagnoses were made. Finally, my arguments are informed by an analysis of the narratives around mental health at various policy and organisational meetings taking place in the settlement during my time in Palabek.

Interviews and observational data were analysed through an inductive approach, which began in the field. During data collection, emerging patterns were identified and discussed with informants and trusted interlocutors to confirm them. Subsequent interviews were conducted to further verify the plausibility of the findings. Informal interactions and discussions with trusted interlocutors in Palabek significantly shaped the trajectory of my research. The importance of these exchanges cannot be underestimated, as they are integral to ethnographic work and serve as powerful reminders that any form of knowledge is produced in intersubjective encounters (see e.g., Jackson 1998). Yet, a social justice-informed analysis such as the one that I seek to put forward in this article cannot prescind from an acknowledgement, however uncomfortable, of the profound power imbalances that underline (and indeed enable) ethnographic research practices in severely under-resourced environments such as Palabek refugee settlement. I am acutely aware that my field research was in many ways facilitated by the significant privilege which my position of researcher granted me, especially in gaining access to the field site. Furthermore, my race and social class meant that researcher-informant relationships were always characterised by profound power asymmetries, which I did my best to mitigate by emphasising the voluntary nature of research participation and ensuring complete confidentiality during interviews and conversations. Following the methodological suggestions of the decolonial scholarship which informs my fieldwork practice (e.g., Smith 2012, Simpson 2007), I discussed findings with my research assistants, translators, and closest relations in the field, keeping in mind that both my whiteness and intellectual positionality inevitably informed what I was observing.

Ethical approval for this study was obtained from the London School of Economics (LSE), Uganda National Council for Science and Technology (UNCST) and Ugandan Office of the Prime Minister (OPM).

Resilience, Mental Health, and the Neoliberalisation of the Global Migration Regime

In recent years, the search for durable solutions for refugees and forced migrants has become one of the most pressing issues facing the international community. In 2021, the number of forcibly displaced people worldwide reached the record-high of 89.3 million, including over 27 million refugees (UNHCR 2022a). Protracted refugee situations, where displacement lasts for over five years, are a reality for 80 per cent of refugees and are quickly expanding, particularly across the Global South. Overall, the ever-expanding nature of forced migration poses major obstacles to the 2030 Agenda for Sustainable Development goal to ‘leave no one behind’ (UNHCR n.d.).

At a time in which the increasing resistance of countries in the Global North to accept refugees and asylum seekers severely restricts possibilities for third-country resettlement (Hansen 2018), resilience became a central notion in refugee policy. In refugee situations, resilience-focused narratives portray resourceful and mutually supportive individuals and communities able to cope with crisis (Cretney 2014), implying that pathways to durable solutions can be found in the countries of arrival of forced migrants. Crucially, since 2016 ‘resilience and self-reliance’ is one of the core pillars of the Comprehensive Refugee Response Framework (CRRF), the latest refugee management strategy adopted internationally. The centrality of resilience in the CRRF signals a major shift in ideas on the nature of crisis and disaster in policy and academic literature, as well as the establishment of what scholars have called resilience or resiliency humanitarianism (see Ilcan and Rygiel 2015, Hilhorst 2018, respectively) – that is, an approach to aid centred around people’s existing capacities to recover.

As noted by Felli, the adoption of the notion of resilience in development discourse is ‘much less theoretical and much more instrumental’ (2016, p. 23). Resilience is hardly an operational term, but rather a descriptive and aspirational one; as such, it needs to be understood in combination with the notion of ‘self-reliance’, with which resilience is often paired. Self-reliance is described as the ability of individuals and communities to meet essential needs in a sustainable way (UNHCR 2005), ultimately to gain independence from humanitarian assistance. Far from being a new idea in refugee policy, self-reliance has been at the centre of UNHCR entrepreneurship-focused initiatives at least since the 1960s, to the extent that it is often portrayed as ‘the holy grail of global refugee management’ (Betts et al. 2017, p. 13). The concepts of resilience and self-reliance are not to be understood as synonyms, but rather as mutually reinforcing notions. As stated by a UNHCR Executive Committee Report: ‘Self-reliance can lead to resilience, while resilience is necessary to ensure that progress towards self-reliance is not eroded or reversed in the face of sudden-onset shocks and longer-term trends, such as climate change’ (UNHCR 2017, p. 3, Oliver and Boyle 2019). Under resilience frameworks, self-reliance approaches to refugee management have been reinforced and expanded worldwide.

The introduction of resilience discourses has been described as a gateway for states and other actors to normalise neoliberal governmentality,¹ as the imperative to ‘be resilient’ shifts responsibility onto individuals who are expected to self-govern, be self-aware and adaptable through crisis (Joseph 2013, Welsh 2014). Recent literature argues that resilience humanitarianism, too, operates as a mode of neoliberal governmentality, by constructing refugees as responsible economic subjects and forced displacement crises as opportunities to ‘catalyse economic and social development’ in refugee camps (Ilcan and Rygiel 2015). The increasing relevance of resilience-focused approaches in humanitarian policy highlights a shift in the conceptualisation of emergency, increasingly understood as in continuity with normalcy rather than disrupting it (Hilhorst 2018). Scholars have argued that similar ways of framing risk, uncertainty, and crisis are central features of neoliberal governmentality (Krause and Schmidt 2020). While the notion of emergency ‘has been internalised and normalised as integral to the functioning of society’ (Duffield 2012, p. 481), crisis has become ‘the new normal’, and resilience the necessary technology of the self that individuals and communities must develop to thrive in it (Joseph 2013). Accordingly, the narrative around refugees has largely abandoned their characterisation as passive aid victims, instead constructing them as ‘the lean, agile and adaptive subject that [… .] thrives in the fitness landscapes of permanent emergency’ (Duffield 2015, p. 139, emphasis in the original).

The resilience-turn in humanitarianism is not the only significant shift to have recently changed the face of humanitarian aid. Over the past two decades, a growing body of literature has advocated for the integration of mental health interventions into humanitarian responses to war and disasters, arguing that such programmes can promote processes of social healing and post-conflict reconstruction (Tol et al. 2011, WHO 2017). As a result, the field of mental health in humanitarian settings has flourished, coming to constitute a new branch of aid known as mental health and psychosocial support, or MHPSS (Jones and Ventevogel 2021). This is not without reason; refugees and other war-affected populations are widely recognised to be particularly at risk of experiencing mental health problems. Recent estimates from WHO state that over 20 per cent of refugees will experience mild or moderate mental disorders (e.g., depression, anxiety disorders, and post-traumatic stress disorder or PTSD), while about 4 per cent may experience severe disorders, such as schizophrenia, bipolar disorder, and major depression (Charlson et al. 2019).

With the expansion of the MHPSS field, however, humanitarian emergencies have been increasingly understood as mental health crises (Summerfield 1999). The expansion of MHPSS interventions has resulted in the increased psychologisation of non-Western populations, in what has been described as a form of ‘therapeutic governance’ of post-disaster subjectivities and societies (Pupavac 2001). Nevertheless, MHPSS interventions are now an integral part of humanitarian response to crisis worldwide. The growth of the MHPSS field, particularly in the Global South, is part of the global expansion of a body of lay and professionalised knowledge about the mind which authors have referred to as ‘psy’ (e.g., Vorhölter 2019) or ‘psy-expertise’ (Klein and Mills 2017). Ranging from psychiatric approaches to psychodynamic ones and self-help culture, psy is conceptualised as a broad complex of discourses, practices, and institutions, productive of a psychological self. Psy narratives and interventions largely uphold a psychocentric worldview (Rimke 2016), shaped by assumptions that individual suffering is an effect of ‘the individual mind […] rather than a product and expression of social, political, historical, and economic problems’ (Rimke 2020, p. 38).

While scholars have pointed out the historically co-constitutive relationship between development practice and psy-expertise, and highlighted their shared colonial history (e.g., Mahone and Vaughan 2007, Howell 2011), in recent years psychological interventions have been increasingly mobilised in development programmes throughout the Global South. This phenomenon is largely the result of a push for the worldwide expansion of psy-expertise originating from the field of global mental health (GMH), a growing assemblage of academic and policy literature which has recently catalysed attention and funding, and whose approach is now widely embraced by the World Health Organisation (WHO). Firmly rooted in Western psychiatric nosology and practice, the illness model of mental health promoted by WHO and GMH understands mental disorder as universal, framing psychological distress as an ‘illness like any other’ (Mills 2018).

Both WHO and GMH have been vocal in calling ‘to scale up the coverage of services for mental disorders in all countries, but especially in low-income and middle-income countries’ (Lancet Global Mental Health Group 2007, p. 87). The enthusiasm that this proposition has catalysed needs to be understood within what Mills (2015) refers to as the ‘mental health-poverty nexus’ – a dominant discourse establishing a close relationship between mental ill-health and chronic poverty, thus portraying mental illness as an obstacle to national and international development agendas. Consequently, mental health has emerged as one of the new frontiers and ‘global priorities’ of development policy, explicitly demonstrated by its inclusion in the Sustainable Agenda for Development in 2014. As the GMH field emerges as a recognised actor in humanitarian action (Bäärnhielm et al. 2017), mental health interventions are increasingly framed as essential to enable people to lift themselves out of poverty, particularly in crisis-struck low- and middle-income countries (Mills 2018). Development is thus increasingly understood as ‘a problem of the mind’ (Howell 2011, p. 98) to be approached with psychological solutions. Echoing Li (2007)’s considerations on the reductionism and depoliticisation brought about by development interventions, Mills (2022) has noted that a universal approach to mental health constructs psychological suffering as a technical problem, removing the social, political, and economic circumstances by which it is shaped and in which it is embedded.

The worldwide expansion of psy has not gone unchallenged. Medical anthropologists have shown that mental health interventions implemented outside of Euro-American contexts often impose Western understandings of mental health, mental illness, and personhood (Kienzler 2008,Summerfield 2008). These notions, they argue, have questionable cross-cultural applicability, and risk disregarding culturally relevant and available forms of support (Summerfield 1999). Critical scholars have also noted that psy practice understands and classifies social phenomena as individual traits, masking political and economic determinants of psychological distress (Mills and Fernando 2014). Crucially, the individualisation and reductionism characterising psy-expertise configures it as consistent with the dynamics of neoliberal capitalism. Authors inspired by Foucault have described the psy complex as a form of intimate governance, pointing out the distinctive neoliberal logic which underlies the expansion of Western psy-expertise (e.g., Rose 2006, Rimke 2016). Marxist critiques, on the other hand, note that contemporary psychological and psychiatric systems within neoliberal capitalism distinguish between individuals who are able to contribute to the free market and those who are not, upholding the logic of neoliberal societies where personal value is predicated on one’s ability to produce and perform (e.g., Tseris 2017).

Both resilience and psy frameworks gained prominence in the context of the current humanitarian response to the global refugee crisis, at a time in which the aid industry is particularly dominated by market-centric, neoliberal imaginaries (Oliver and Boyle 2019). As detailed above, resilience humanitarianism is rooted in a neoliberal approach to refugee camps and settlements. Under this framework, such spaces are constructed as sites of individual and collective improvement. Indeed, here the psy complex has become a technology of development; mental health is increasingly tackled through brief cognitive or ‘self-help’ interventions in refugee settings (see Torre 2021), often embedded in narratives of self-improvement and entrepreneurship. In this sense, the individual and psychocentric focus of the Western mental health interventions fits neatly within the expansion of development-oriented policies enacted under the framework of resilience humanitarianism.

Crucially, these same neoliberal theoretical structures have also significantly shaped a new understanding of emergency, which is now often framed in policy discourse as ‘a moment and site of profound opportunity for societies to transform themselves so that they might be governed differently’ (Reid 2010, p. 404 in Welsh 2014). Thus, if mental health is the way out of crisis and towards development, crises provide vital opportunities to expand psy discourses and interventions. As its ‘Building Back Better’ report explicitly states (WHO 2013), the WHO identifies the aftermath of crisis and disaster as the best-suited environment to introduce policies aimed at the expansion of mental health services in low- and middle-income countries (Epping-Jordan et al. 2015).

The growth the psy in Uganda clearly exemplifies this process. Over the past three decades, Uganda has been undergoing extensive neoliberal economic reforms (Wiegratz et al. 2018), becoming a well-known ‘donor darling’ of international development programmes. Meanwhile, the country has recently seen a remarkable expansion of psy discourses and expertise, in large part thanks to the widespread presence of MHPSS interventions (Vorhölter 2019). Northern Uganda, a region which between 1986 and 2006 was devastated by a long and bloody civil war (Allen and Vlassenroot 2010, Meinert and Whyte 2017), has provided particularly fertile ground for the introduction of mental health programmes. Throughout the conflict, northern Uganda became the case study par excellence of war-related trauma, with countless humanitarian organisations flooding the region to heal the ‘invisible wounds’ caused by the conflict. Their work consisted of various forms of trauma therapy, often haphazardly implemented, and scarcely monitored (Torre et al. 2019).

Today, the region is again targeted by a variety of psychological programmes, this time as part of the humanitarian response to the huge refugee influx in Uganda. In what follows, I provide an ethnographically-informed overview of life in Palabek, one of Uganda’s thirty refugee settlements. I focus particularly on the widespread food insecurity that settlement residents regularly experience, and analyse the role that psy discourses and interventions play in this humanitarian landscape.

Resilience Policies and Food Insecurity in Palabek Refugee Settlement

In recent years, Uganda has often been depicted by international media and organisations as a model for refugee integration thanks to its self-reliance and development-oriented approach to displacement, gaining a precious reputation as an example of successful refugee management (see e.g., Clements et al. 2016). Self-reliance policies were introduced in the country through the 1999 Self-Reliance Strategy (SRS), and then maintained under subsequent and policies, including the current CRRF (IRRI 2018). It is therefore unsurprising that when the resilience-focused Comprehensive Refugee Response Framework (CRRF), the latest international refugee management policy described earlier in this article, was piloted in selected refugee situations around the world, Uganda was one of them. Under current laws, refugees are allocated a plot of land, which they are expected to cultivate to achieve a sustainable source of income, and consequently independence from humanitarian assistance. Refugees across Uganda are also granted the right to work, to move freely within the country, and to access free UNHCR-funded education and health services.

However, the potential of current policies for allowing refugees to achieve independence from humanitarian assistance in Uganda has been grossly overstated, and scholars and activists have often denounced the frequent unavailability of freedoms and rights to refugees across the country (IRRI 2015, O’Byrne and Ogeno 2020). Yet, self-reliance policies in Uganda continue being implemented, and indeed expanded under current resilience-focused frameworks. Titeca (2022) has argued that this is largely due to the relation of mutual dependency that Uganda and the European Union entertain with regards to refugee management; the former dependent on international funding, the latter in need of a refugee policy success story to prove the efficacy of Global South-focused solutions.

In Palabek refugee settlement, where the research informing this article was conducted, refugees’ everyday lives are deeply shaped by the shortcomings of self-reliance policies. Due to the extreme scarcity of resources and stagnant economy characterising the area surrounding the settlement, refugees in Palabek cannot easily benefit from participation in the regional economic market. For many, therefore, subsistence farming and small-scale market activities within the settlement constitute the main pathway to the achievement of independence from humanitarian assistance. However, this is often challenging, as the plots allocated to refugees are too small to constitute an actual means of livelihood, and the land mostly too rocky or swampy to grow anything other than small amounts of vegetables. Some refugees rent unused land from Ugandans living close to the settlement; for many of my interlocutors, however, this choice resulted in their labour being exploited without any economic gain for them, as they were often chased away after having merely prepared the soil for plantation. Buying a plot of land for agricultural use, meanwhile, requires an availability of resources simply unthinkable for the overwhelming majority of refugees.

If cultivation does not emerge as a realistic pathway to the achievement of self-reliance, the corruption and structural failures characterising the Ugandan refugee emergency response (O’Byrne 2022,Titeca 2022), pose additional challenges in this sense. Food rations across Ugandan settlements have never been adequate to meet the needs of the overwhelming majority of refugees (IRRI 2018). In Palabek refugee settlement, most people experience significant and chronic food insecurity, particularly during the dry season when the gaps left by the insufficient humanitarian aid cannot be filled by vegetables grown in the plots. Communities employ a variety of self-protection strategies to face external threats and secure basic needs (Gorur and Carstensen 2016, Paddon Rhoads and Sutton 2020). To avoid going hungry in Palabek, refugees often brew and sell alcohol, cut grass to sell in the market, or perform various forms of leja-leja, odd temporary jobs, mostly for Ugandan nationals (see e.g., Wilhelm-Solomon 2016), to try and earn small amounts of money. Often, people will rely on family relationships and neighbours for help; however, as one informant explained, doing so offers only temporary relief:

When food is over, there’s nothing we can do, especially in dry season when there’s not even greens in the house. We can sometimes borrow from neighbours, but then the next month you have to give them back [what you took], and you are left with little food again.

As displacement often disrupts existing networks (Easton‐calabria and Herson 2020), not everyone is able to rely on existing relations. Furthermore, most people resort to selling a significant share of their limited food supply to purchase essential items like soap, medicines, school supplies for children. When asked about how she and her three young children managed without the maize she had had to sell to afford soap, one widowed refugee woman shrugged: ‘We reduce on what we eat. We eat once per day’. Palabek settlement has the highest malnutrition rates in Uganda, estimated to be as high as twelve percent (IPS 2019).

O’Byrne and Ogeno (2020) have shown that food insecurity in Palabek settlement is one of the main reasons leading many refugees to often travel back to South Sudan. They make the journey to look for employment or farm on their ancestral land, in an attempt to overcome inadequate humanitarian assistance, secure livelihoods, and earn a small income. This is not a choice devoid of risk. Although some areas are intermittently free from violence, South Sudan remains a politically unstable context, where the conflict is still ongoing and ceasefires are volatile (ICG 2021). Crossing the border often results in deadly outcomes. As an older Acholi-speaking refugee recounted: ‘One of my friends left the settlement to go back [to South Sudan]. He was a teacher, but there was no work for him here in Uganda. He was killed after only two weeks’.

Yet, resilience policies and narratives emphasise refugees’ need to be adaptable to continuous adversity, constituting a discursive tool which enables the continued pseudo-implementation of self-reliance policies. However, rather than allowing for economic independence and self-sufficiency, ‘resilience and self-reliance’ policies in Palabek mask the failings of the humanitarian institutions responsible for food insecurity in the settlement, which expose people to the risk of violence, and establish cycles of indebtedness and impoverishment that become increasingly hard to break. In doing so, such policies effectively work against refugees’ wellbeing. In Palabek settlement, resilience humanitarianism translates into the political abandonment of refugees by legitimising the withdrawal of support despite widespread and continuous food insecurity.

Mental Health and Political Abandonment in Palabek

The mental health needs of refugees in Uganda have been described as dire and largely unmet (Adaku et al. 2016, Chiumento et al. 2020). Often, studies point out a direct link between the harsh socio-economic conditions that refugees face in the country, and the negative consequences on their wellbeing (Bukuluki et al. 2020, Robinson et al. 2022). The relationship between socio-economic challenges and poor mental health conditions is well-established in the academic literature (Roberts et al. 2022). In particular, food insecurity emerges as prominent in contributing to poor mental health outcomes, and recent studies have shown the correlation between food insecurity and mental health conditions, such as depression and anxiety (e.g., Jones 2017, Pourmotabbed et al. 2020). The scarcity of food resources implies a lack of economic assets that refugees can build on to effectively achieve self-reliance and envision a future for themselves and their families, generating feelings of deprivation, hopelessness, and shame (Trudell et al. 2021).

In Palabek refugee settlement, psychological suffering is particularly widespread (ANS 2020). Psy interventions within the settlements are delivered in various forms – ranging from public trainings delivered to refugees or humanitarian workers, to short-term interventions such as Cognitive-Behavioural Therapy (CBT), to the recent inclusion of psychiatric consultations and mental health clinic days in the settlement’s health centres.

As part of my wider doctoral research, I sought to understand whether the distress that strikingly emerged from my ethnographic findings would be reflected in clinical encounters between refugees and mental health medical staff. In addition to conducting participant observations during clinical interviews, therefore, I analysed the settlement’s mental health clinic’s records, focusing in particular on the time of the year when specific diagnoses were made. This observational study revealed that, for at least two consecutive years, the percentage of patients diagnosed with moderate or severe depression between early December and late March more than doubled in comparison to those in October and November. The time intervals are noteworthy; while the latter is the peak of rainy season, the period between December and March coincides with the peak of dry season, when food is at its scarcest within the settlement. The sharp increase of depression diagnoses during this time indicates therefore a strong relationship between access to food, general scarcity of socio-economic resources, and psychological distress in Palabek refugee settlement.

The relevance of the relationship between access to food and mental health was confirmed in interviews by mental health staff in Palabek, who also pointed out an opposite seasonal trend in Ugandan citizens’ depression rates. Across the region, people usually experience various degrees of food-related hardship between May and July, during the peak of the wet season which precedes the first harvest (Schramm et al. 2016).² While also experiencing frequent socio-economic difficulties, Ugandans with access to land can employ a variety of coping strategies to mitigate the hunger gap (Twecan et al. 2022). Most refugees, on the other hand, are almost entirely dependent on food aid for all food items, with the exception of what they are able to cultivate on their plots. While regular rains offer some respite as small amounts of vegetables can be grown to complement the insufficient food items they receive, during the dry season avoiding long periods of hunger becomes impossible for many. As explained by a psychiatric nurse working in Palabek, who regularly attended to both South Sudanese and local Ugandan patients and often reflected on the impact of socio-economic factors on his patients’ wellbeing:

There is a big seasonal difference between mental illness in refugees and in [Ugandan] nationals. For the nationals, in dry season they are less stressed, they associate with others more often because all the funerals and celebrations are happening then. They can visit people and get money by selling part of their harvest, while in rainy season there is a lot of work to do and then you see depression rising. But for the refugees it is the opposite. Here during dry season, you will see many people with stress disorder and major depression. It is strongly food-related: the food given is little, and you have to sell some of it to buy things like salt, whereas in rainy season people can plant some things and at least change diet.

These words lucidly illustrate the impact of the failures of the Ugandan humanitarian response on refugees’ psychological wellbeing. As it emerges from an analysis of the mental health clinic’s records, as well as from interviews with both refugees and mental health workers, in dry season the failures and shortcomings of the Ugandan humanitarian response become particularly evident. The pseudo-implementation of self-reliance strategies, in the form of inadequate food rations and lack of suitable plots of land, is directly linked to psychological distress in Palabek. While at least six national and international NGOs were implementing various MHPSS programmes in Palabek at the time of research, these interventions were far from able to provide meaningful care and support for refugees, and instead reinforced the conditions contributing to refugees’ psychological affliction. In what follows, I present ethnographic examples of two manifestations of the psy in Palabek: the instrumentalization of mental health discourses in public and political contexts, and the inclusion of financial trainings within a short-term community psychosocial intervention.

The Entanglements of Resilience Policies and Psy Discourses in Palabek

With mental health higher than ever on the humanitarian and development agenda, in October 2019, the Ugandan Office of the Prime Minister (OPM) and UNHCR, which jointly manage the refugee crisis in the country, organised a formal open celebration in Palabek settlement on the occasion of World Mental Health Day. Staff from all the NGOs providing mental health services in the settlement were invited to attend, alongside refugee representatives, settlement residents, and host community members.

The celebration took place in a wide field in front of a primary school, where several rows of plastic chairs had been placed under a tent. Under the burning dry season sun, NGO representatives delivered presentations of their programmes, followed by appreciative speeches by refugee leaders and statements by UNHCR and camp management officials. The extract of a speech delivered in English by a prominent OPM official is worth pointing out. With the help of a translator, he addressed the refugees:

We are not in an emergency situation here anymore, we are in a development situation. I want to tell you that assistance will be reduced. People here are drinking a lot of alcohol, which is one cause of mental illness; they should stop drinking, and instead be busy. The time for emergency has passed, and you have been supported; you should now create your own jobs here in the settlement.³

Behind him, on a huge plastic banner hung between two trees read the slogan: ‘Think Positive: Save a Life’, echoing the ‘suicide prevention’ theme of that year’s World Mental Health Day. Refugees listened in silence; a group of women, sitting on mats far from the open area where the speech was being delivered, looked at the OPM representative and chuckled. My research assistant, sitting beside me on a white plastic chair, listened to his words with a serious look on his face. He then commented: ‘But how can we be busy if we do not have land and there are no jobs in the settlement?’

It is worth noting that the attribution of mental disorders to the consumption of psychoactive substances, and especially of alcohol, was not novel; rather, it was often evoked during psycho-education sessions and humanitarian coordination meetings taking place in the settlement. In interviews and casual conversations NGO workers and refugees often remarked, in a matter-of-fact manner, that poverty and unemployment led people to alcoholism. This is a causal dynamic well-established in policy and academic literature (see e.g., Marlow et al. 2021), and particularly widespread in the social worlds in which the lives of refugees and Ugandan workers alike were embedded (see e.g., Meinert and Whyte 2017). Yet, in both political and organisational discourse in Palabek, the relationship between states of unemployment and alcoholism was left unaddressed or denied – at times with paradoxical results. For example, in the course of a mental health-focused inter-agency meeting, OPM officials proposed to tackle the rampant issue of alcoholism among refugees in Palabek by issuing a settlement-wide policy that would outlaw brewing and selling alcohol. A loud hum suddenly filled the room – an unusual occurrence, given that the rigid vertical structure of these meetings generally discouraged disagreement from participants. Immediately, an employee of a livelihood-focused NGO stood up and spoke to the OPM official leading the session:

Making the brewing or drinking of alcohol illegal is not the answer. This is an income generating activity … we need to engage people in other income-generating activities if we want it to stop. I have gone to these people, I have had a focus group discussion to understand the drinking issue. This is a psychosocial issue; people drink to forget, because there is nothing for them to do in the settlement.⁴

Other NGO workers, several of whom had been working in the settlement for extended periods of time, nodded and murmured in agreement. For a couple of minutes, it seemed many of them had anecdotes from their field activities that confirmed their colleague’s argument and were eager to discuss them. The OPM official did not engage with the NGO worker’s comment, instead repeating that steps towards the outlawing of alcohol production would be considered. Eventually the buzz dissipated, and the coordination meeting continued uneventfully.

Financial Trainings as Mental Health Interventions: Psychiatrising Poverty

A group of around thirty South Sudanese women are gathered under the shade of an iron sheet and UNHCR-marked tarpaulin structure. Despite it being early in the day, the heat underneath the roof is suffocating. It is mid-November, and we are approaching the end of rainy season; the rains have already become heavier and shorter, which many people are worried will mean that this year’s dry season will start sooner than usual. Deforestation and climate change have heavily affected the seasonal rainfall patterns in the region, which has become more unreliable over the past few years. The women sit in silence on mats on the floor, some playing with the small children they brought along, taking them outside when they get too restless.

The structure where the refugees are gathered serves both as an Anglican church on Sundays and as a community meeting point. Today it is the site of a ‘financial literacy’ training, delivered by one of the main NGOs working in the MHPSS field. This is standard procedure for this organisation and many similar ones. NGO employees tour each area of the settlement and carry out diagnostic interviews with refugees that have been previously identified by local leaders. Those that fit the psycho-diagnostic criteria for depression or PTSD qualify for taking part in the programme, and are divided in groups of ten or twelve participants. Over the next months, the groups undergo ten sessions of Cognitive and Behavioural Therapy (CBT-T) for trauma. Once the sessions are over, representatives from the groups receive a one-day financial training where they are taught basic trade skills (e.g., keeping books and managing savings). Shortly after, the original groups each receive a sum of money (usually up to 600,000 Ugandan shillings, around 155 US dollars) to start a communal business. Only individuals who have undergone CBT are entitled to partake in the business creation. By requiring refugees to undergo a form of therapy in order to access financial resources, this programme establishes a straightforward relationship between mental health and entrepreneurial economic ability – and by the same logic, between mental illness and poverty (Torre 2021). The trainer explains the refugees: ‘You have been through ten CBT sessions; this means you are now doing well, so you have to do something’. Throughout the training, conducted in Acholi and translated in Arabic by one of the women for the non-Acholi speakers present, the linguistic register of mental illness is employed several times as a metaphor for poor entrepreneurial spirit: ‘If you go to the market and buy a cup of lacere [small fish] for 500 shillings and then sell it again for 500 shillings, people will say you are mad in the head!’.

The atmosphere is tense. Just a couple of days ago, the UNHCR announced that this month refugees will receive sorghum instead of maize, while beans will not be distributed. The causes are unclear – some UNHCR and OPM representatives speak of funding shortages, others blame heavy rains ruining the harvest of beans near Kampala. This is not good news; most refugees wholeheartedly dislike sorghum, claiming it is inedible and often falling ill after eating it. However, not receiving beans is a different issue altogether. It is the first time since the beginning of 2018, when food non-delivery was a serious issue for several months (see O’Byrne 2022), that refugees have been left to fend for themselves for a major part of their basic dietary needs. Throughout the settlement, people are upset and worried; those who can are travelling back to South Sudan hoping to harvest vegetables to bring back to Palabek. Rumours have quickly spread that this may not be a one-time occurrence, but a permanent change. This is cause for grave concern among refugees; if that were to be the case, how will they survive? ‘For one month, people can still manage – greens are still there in the garden. But what about when dry season comes? People are crying that they will die’, a young man commented when the news spread, shaking his head. ‘This is how the Ugandan government is telling us they do not care if refugees starve to death’.

The NGO worker delivering the training seems to think differently. After explaining selling prices and business growth, the trainer discusses the choice of a good product to market. Beans, he says, would be a strategic choice right now:

Yesterday someone told me that World Food Programme is not going to give beans this month. I said, you are very rich now! Go to the village and bring beans to sell, you will make a lot of money because people here don’t have beans. Like a coffin-seller who won’t be sorry for the person who died but instead happy for the business opportunity, don’t mind about World Food Programme!⁵

Discussion

Following Kapferer (2015) and Das (1996)’s approaches to event description, I consider the vignettes above as critical ethnographic moments allowing for an illustration and analysis of problematics that emerge during anthropological work. In this sense, the scenarios described above are particularly relevant for the purpose of this article, as they show how mental health narratives are selectively employed in policy and community settings in Palabek refugee settlement. The psy complex emerges in both instances as instrumental in justifying decisions to withdraw aid distribution, while psychocentrism serves as a political tool masking institutional responsibility for refugees’ socio-economic hardship. This, I argue, enables the state’s structural violence towards refugees, as well as their political abandonment (Duffield 2015).

To be clear, I am not suggesting that the abandonment of refugees is achieved simply through the introduction and wide-scale implementation of mental health interventions; indeed, the process through which refugees find themselves abandoned by the Ugandan state and international humanitarian institutions is a complex one, which is attained through a multitude of strategic political choices in the management of the country’s humanitarian apparatus, and shaped by the encounter of global interests around the management of forced migration with local development agendas, corruption dynamics, and social and historical realities of mobility. However, in practice, psychological programmes and narratives are often used by state and non-governmental organisations in support of arguments which lead to refugees’ abandonment. This is particularly significant in the context of Uganda’s refugee politics. As argued by Titeca (2022), Uganda is dependent on refugees’ presence to maintain its status of trusted recipient of Western development funds; at the same time, the country’s pseudo-implementation of self-reliance policies – in the form of lack of adequate assistance and land provision to refugees – ultimately reveals a lack of political will towards refugees’ effective self-reliance and long-term residence in the country.⁶

The combination of these factors results in an assistance landscape fraught with contradictions, where Uganda is able to solidify financial streams while disengaging from refugees’ needs and social realities through forms of political abandonment, such as scenarios in which refugees are still granted entry and status into the country, but denied protection and possibilities of self-sufficiency and future-making. One such strategy resides in the shift of responsibility for economic survival in arguably impossible circumstances onto individuals themselves, blurring the ethical lines of institutional obligation and leaving refugees to fend for themselves. As this article shows, mental health and psychosocial interventions become intimately shaped by the moral and political economy of aid delivery in the context where they are introduced. In Palabek refugee settlement, these programmes and narratives are effectively manipulated to justify institutional failures, corruption incidents, and human rights violations, they should be understood as a political tool contributing to the Ugandan state’s abandonment of refugees.

The on-the-ground manifestations of this phenomenon are illustrated by the ethnographic vignettes above. In the first example, a mental health event is selected by OPM officials as the occasion to announce the decrease of already insufficient aid distribution, which refugees are encouraged to navigate through self-entrepreneurship. The joint mobilisation of development and psy discourses, coherently with the logic of the ‘mental health-poverty nexus’ (Mills 2015), allows government representatives to blame refugees for their socio-economic hardship, and to medicalise the causes leading to the latter. Mental distress, on the other hand, is constructed as caused by discrete individual behaviours, such as alcohol consumption, rather than by the structural barriers to survival and self-reliance brought about by the failings of the Ugandan humanitarian response. The attribution of causality of mental distress emerges here as a crucial and politically connotated process. In the inter-agency policy meeting described, suggestions that alcohol abuse should be understood as an expression of social suffering were disregarded. While alcohol abuse is a widespread phenomenon in refugee contexts across East Africa (e.g., Chiumento et al. 2020), ignoring its social roots places the responsibility for current socio-economic hardship on individuals, rather than on systemic failures. The medicalisation of social suffering has very real effects. The shifting of responsibility from institutions to refugees themselves constitutes here a significant political, discursive, and operational tool which effectively allows institutions to avoid accountability for the neglect of refugees’ protection, and for the violation of their human rights.

As the second scenario shows, this view is pushed even further in therapeutic settings such as those of community psychosocial interventions. With the incorporation of financial trainings within Cognitive-Behavioural Therapy, the causal link between mental health disorders and chronic poverty is reiterated. In addition, in these hierarchical therapeutic spaces, refugees are encouraged to understand the lack of humanitarian assistance as a chance to develop self-entrepreneurship, which the context of the training explicitly identifies as a manifestation of good mental health. The links between the psy complex and resilience narratives emerges here as most relevant, showing that in the context of Palabek settlement self-reliance is constructed as not just an economic, but a psychological condition in which people ‘do not look to states to secure their wellbeing because they have been disciplined into believing the necessity to secure it for themselves’ (Welsh 2014, p. 21). Crisis and the threat of serious food insecurity are here presented as a chance to thrive, while resilience becomes a skill that must necessarily be developed and mobilised as a technology of ‘self-enhancement’ (Howell 2015) to navigate adversity and chronic crisis. This depoliticising shift of responsibility allows for impunity in the Ugandan government’s political abandonment of refugees to a state of permanent emergency, as individualised psychiatric labels provide institutions with an alternative explanatory model for refugees’ failure to achieve a state of self-reliance.

In recent years, concerning reports of a significant increase in suicides in refugee settlements across Uganda have emerged (Bukuluki et al. 2021, Bwesige and Snider 2021). In Palabek settlement alone, suicide attempts more than tripled between 2020 and 2021 (UNHR 2022b) – a period during which Uganda experienced a long and strict lockdown due to the COVID-19 pandemic, and emergency assistance to refugees underwent significant cuts (Stein et al. 2022). In the wake of these reports, UNHCR has called for more mental health interventions to be implemented in Ugandan settlements (UNHCR 2020). However, this article highlights the dangers of approaching refugees’ wellbeing from a strictly psychocentric perspective. Well exemplified by the slogan ‘Think Positive: Save a Life’ chosen for World Mental Health Day in Palabek, psychocentrism allows to disregard the impact of socio-economic elements on refugees’ mental health. While the mind is stripped of its social components and understood solely as what lays ‘between the ears’ (Summerfield 2012, p. 527), change is constructed as only possible through self-improvement, and devoid of systemic and structural determinants. Where space should be created for institutional accountability, the individualisation and medicalisation of socio-economic distress instead invalidate and depoliticise refugees’ legitimate claims.

This research shows the ways in which, as argued by Rimke, psychocentrism represents ‘a form of social injustice, where individual reformation rather than social and economic justice is promoted’ (2016, p. 5). While this consideration applies widely, in Palabek refugee settlement an ulterior and crucial paradox warrants attention. In this context, observations, interviews, and clinical records show that inadequate assistance and food insecurity are intimately related to psychosocial suffering. The words of the psychiatric nurse on page 13 of this article clearly highlight the causal link between the inadequacy of the humanitarian response and forms of individual and social suffering among refugees. In Palabek settlement, psy discourses and practices do not simply intersect with resilience ones to uphold aid cuts; rather, existing MHPSS programmes are set out to address manifestations of psychological suffering largely caused by the failures of the humanitarian response, in which such interventions are embedded. When analysed through a social justice perspective, therefore, the psy complex in Palabek refugee settlement appears to serve not refugees’ mental health, but rather the humanitarian apparatus itself.

Conclusion

Within the Ugandan humanitarian landscape, psy expertise, social injustice, and resilience frameworks are to be understood not just as closely conceptually interrelated, but as mutually reinforcing. In allowing for the expansion of psychocentric understandings of refugees’ socio-economic challenges, resilience policies in Palabek dilute the political significance of manifestations of refugees’ individual and social suffering, obscuring institutional responsibility of state and non-governmental organisations tasked with the protection of refugees. Furthermore, in Palabek settlement, current psy discourses and interventions are employed in both policy and therapeutic settings as political devices that shift responsibility for individuals’ economic and psychological survival unto refugee themselves. In so doing, psychocentric MHPSS programmes facilitate the structural and political abandonment of refugees by constructing the latter’s socio-economic distress as a medical entity, rather than an outcome of institutional neglect.

The political instrumentalization of psy knowledge and practices is by no means a new problem; rather, it is a phenomenon with deep colonial roots and pervasive global legacies (see e.g., Fanon 1964, Mahone 2006). Yet, it is an issue particularly worth addressing given the increasing expansion of psy expertise in low-resource settings, due to increasing humanitarian and global mental health presence in the Global South. The potential of mental health assemblages for providing meaningful support is not to be entirely disregarded; for example, Vorhölter (2019) has shown that middle-class Ugandans find significant comfort in forms of psychotherapy which have recently gained popularity in the country’s capital. The socio-economic characteristics of the context in which interventions are introduced, however, fundamentally shape their meanings and implications, as well their users’ priorities and experiences of suffering. In resilience-centred settings such as Palabek refugee settlement, the increasing psychologisation of humanitarian aid upholds what Mahdiani and Ungar (2021) refer to as ‘the dark side of resilience’; that which hinders structural change and requires refugees to adapt to a life of chronic uncertainty.

Therefore, serious questions need to be raised about the ethics of expanding psychocentric MHPSS interventions in the absence of basic resources without first addressing the latter, as well as the structural injustices which underlie circumstances of systemic oppression. There is a real risk that mental health interventions and resilience policies in extremely resource-poor contexts may tend, towards the protection, not of refugees, but of failing Ugandan and international institutions. As emerging studies show, alternatives to psychocentric mental health interventions do exist, which centre users’ priorities and social realities (Jansen et al. 2015, Haushofer et al. 2021). Further research will need to explore the potential of such programmes (e.g., social, livelihood, and cash-based interventions) to generate therapeutic outcomes. Crucially, in doing so it will need to take seriously the role of political, structural, and material circumstances in shaping both refugees’ psychological distress, as well as the significance and implications of mental health interventions themselves.

Acknowledgements

I sincerely thank Dr. Julian Hopwood and Dr. Ryan O’Byrne for their support and insightful comments on previous drafts of this manuscript, and two anonymous reviewers for their helpful suggestions. Finally, I am profoundly grateful to the residents of Palabek refugee settlement for their time and willingness to discuss their lives with me.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

The work was supported by the Rockefeller Resilience Foundation: IGA-Rockefeller Funding Call [IDVTA], and by a ESRC PhD Studentship (ESRC ES/P000622).

Notes on contributors

Costanza Torre

Costanza Torre, MSc MRes, is a PhD candidate at the Department of International Development, London School of Economics and Political Science (LSE) and an affiliate researcher at the Firoz Lalji Institute for Africa (FLIA) at the LSE. Her research explores the socio-political lives of public and mental health interventions in complex emergencies and with minority populations; the current expansion of global mental health thinking and practice in humanitarian emergencies; and the role of structural and social determinants of mental health.

Notes

1. Neoliberalism is here explicitly understood not merely as a manifestation of a specific economic agenda that decentralises the state’s governance function, but as a political project of ‘government at a distance’ that acts directly upon individuals’ subjectivities, encouraging free conduct through a logic of ‘responsabilisation’ of citizens (Dean 2010) and of ‘economisation’ of individuals’ social and political lives (Foucault 2008[1979]).

2. Northern Uganda is characterised by a unimodal rainfall, with a long rainy season lasting generally from March to November (Atube et al. 2022), and a single growing season, with harvesting occurring in August and September (Epule et al. 2021).

3. It is worth noting that the food cuts announced during this speech would come into effect in April 2020, amidst the first wave of the COVID-19 pandemic and sudden national lockdowns on a global scale. The Ugandan lockdown, in particular, involved severe restrictions on movement and was among the longest and strictest in the world. The combination of aid cuts and the lockdown would result in severe consequences for refugees’ livelihoods and wellbeing (see e.g., Bukuluki et al. 2020, Stein et al. 2022).

4. Interagency meeting, Palabek refugee settlement, 27 February 2020.

5. Financial training in the context of CBT-T intervention delivered by the Transcultural Psychosocial Organization (TPO) in Palabek refugee settlement, 14 November 2019.

6. Furthermore, it is worth noting that these circumstances further narrow refugees’ already extremely limited long-term options (Hansen 2018). This is likely to result (and indeed already has) in an increase in mobility towards South Sudan – both in the forms of permanent ‘voluntary returns’ and in the temporary, informal, and livelihood-oriented movement described by O’Byrne and Ogeno (2020). As the latter have argued, the security situation of South Sudan is so dire that refugees’ return to the country, driven as they are by the scarcity of resources in Uganda, represents a significant failure of refugee protection by UNHCR and Ugandan institutions alike.