Q&A with Dr. Costanza Torre, King’s College London

Could you please introduce yourself and your role in the XCEPT programme?

I’m Dr Costanza Torre, and I’m the lead researcher on the South Sudan branch of the XCEPT programme at King’s College London. Our team at King’s is focused on understanding why, in fragile and conflict-affected states (FCAS), some people seek peace and reconciliation, while others pursue violence. In the case of South Sudan, we’ll be analysing this by carrying out a survey and qualitative interviews to understand what role mental health and exposure to conflict, among other factors, play in informing people’s choices of peaceful or violent behaviours. We are hoping that these findings may inform policy decisions around reconciliation. As the South Sudan lead, I’ve been helping to shape the research design, recruiting local researchers, and guiding the implementation of the research.

Tell us about your background. What were you doing before you joined XCEPT?

I describe myself as a medical anthropologist and critical mental health researcher, which is basically a way to make sense of my very interdisciplinary background. I started off by doing a BA and an MA in clinical psychology, but over the course of my studies I realised that I wanted to consider matters in a much more anthropological way. This led me to join a research project in northern Uganda exploring the reintegration of former child soldiers that had been abducted by the Lord’s Resistance Army – with a focus on the psychological consequences of stigmatisation during the reintegration process. After this, I continued working in northern Uganda for my PhD, which I completed in the London School of Economics. Over fifteen months, I lived in Palabek refugee settlement, which was almost entirely inhabited by South Sudanese refugees, and I carried out an ethnography of the mental health and humanitarian interventions that were being implemented in the settlement.

The entrance of Palabek refugee settlement. Credit: Costanza Torre

Northern Uganda was a really important area to research this, because Uganda currently hosts 1.8 million refugees, which is the largest refugee population in Africa, and the sixth highest refugee population in the world. The field of humanitarian psychiatry is undergoing immense expansion, and during my fieldwork a lot of NGOs were implementing mental health interventions around the settlement where I stayed, so it was really interesting to look at what kinds of programmes were being implemented and the reasoning behind them. This showed how international organisations were understanding the experience of refugees and what issues they thought needed addressing. There’s a huge focus on the role of culture in shaping suffering, and rightly so, but I found that very often the socioeconomic context in which someone is living was ignored.

Often, ‘cultural’ factors are evoked to explain why people don’t really engage with emergency mental health interventions. Humanitarian workers and academics often think that, as these interventions rely on biomedical models, they don’t match the way in which people understand their own suffering, which may involve cosmological and spiritual elements, for example. And while sometimes this may be true, in contexts of chronic poverty and food insecurity, people are also unlikely to engage with mental health interventions because they don’t understand them as helping. They see them as tackling problems only in the mind, whereas what they really need is change in their actual circumstances.

My fieldwork had a strong focus on the social determinants of mental health, and I tried to understand the psychological suffering of refugees away from their clinical dimensions, and rather as being linked to the present context, which is the way in which people usually understand and explain their suffering. For example, someone might say that yes, they experienced trauma due to displacement or exposure to conflict, but the cause of their present suffering is actually a result of food insecurity. Throughout my work, I’ve tried to expand on the notion of ‘psychocentrism’, and challenge the idea that, because manifestations of distress are psychological, then the causes of the distress are psychological, and the solution needs to be psychological as well.

The slogan for the celebration of World Mental Health Day in Palabek refugee settlement, October 2019. Credit: Costanza Torre

Do you think there’s scope to run interventions that combine mental health and socioeconomic support, or should the priority be on addressing people’s living situations?

That’s a very good question. As a clinical psychologist, I definitely see the value in mental health interventions, especially if we’re talking about situations in which symptoms may be particularly acute, or if somebody is suicidal or potentially violent. The problem is that we keep separating these two realms, whereas they’re not divided at all. It doesn’t make sense to think of, for example, food insecurity as one thing and mental health as another, because the experience of not having enough food is already a deep psychological experience of suffering and uncertainty.

This tendency to separate the socioeconomic reality from the psychological one doesn’t stand up against anthropological research which tells us that socioeconomic factors are deeply embedded within people’s ‘lifeworlds’. People’s lives are fundamentally shaped by their network of social relations – and social relations are embedded in, and hugely linked to, socioeconomic factors, such as how much food you may have at your disposal or what your housing situation is.

One other point about mental health interventions that’s important to note is that, often, they’re predicated on a strongly individualised model. They look at symptoms, and they look at the individual. This fits in very well in the world of humanitarian interventions which are often focused on ideas of self-reliance and individual resilience, but what we know – and what anthropologists have been saying over and over again – is that this often does not mirror what people care about and the way in which people actually live. People exist in networks, they exist in relationships, and an emphasis on self-reliance doesn’t make sense to societies that are deeply structured by caring responsibilities.

Refugees walk to the Health Centre III in Palabek refugee settlement. Credit: Costanza Torre

Where does South Sudan fit into this model? Is its society structured or understood in a more relational or individual way?

In South Sudan, personhood tends to be extremely relational. Individuality of course exists, but it’s not valued as much as relationships, and people’s worlds often revolve around extended families. This has huge implications for people’s lives, as it puts enormous pressure on the performance of social roles. For example, what we’ve seen in some of the initial findings from our research in South Sudan is how much the value of cattle is linked to men’s ability to be able to perform as a man and to provide for their family. This expectation exists across society, because it’s very often an understanding that is enforced relationally and specifically by women’s practices. For example, in some regions of South Sudan, it’s common for women to write and sing songs praising men that have been particularly good at behaving like ‘men’, while emasculating and mocking men who haven’t lived up to these expectations.

There’s a concept called ‘lived pragmatism’ that I find very helpful in understanding South Sudanese society. It comes from the social and moral anthropology of Africa, and it’s used to explain how, among certain societies, what is real about people is what can be observed from the outside. When it comes to ideas of masculinity, this means that, until you’re seen by others to perform as a man, you often cannot be defined as one. Because personhood is so relational in South Sudan, the idea of not being valued by society is particularly existentially threatening and can have a huge impact on a person’s wellbeing. This was something I saw first-hand during my fieldwork in Uganda, where the inability to work and to provide had enormous consequences on the mental health of South Sudanese refugees. During the dry season, when food shortages were felt in a particularly acute way, depression rates would skyrocket in the settlements. My research suggests that this was related to the heightened stress of resource scarcity, but also to the fact that being unable to perform relational gender roles, such as providing for one’s family, made it even more difficult for people to see a future for themselves.

A refugee shows the small onion harvest he got due to little rain and climate change in Palabek refugee settlement. Credit: Costanza Torre

And this raises another significant issue with mental health humanitarian interventions. Interventions narrowly based on notions of trauma and post-traumatic stress disorder often put the

emphasis on addressing the past traumatic event, and assume that forms of suffering are generally rooted in past traumas. Yet, for many people, causes of suffering are rooted in present circumstances and in their worries about the future, so there’s this temporal disjuncture between intervention priorities and people’s actual experiences. This is a theme that has come up time and time again in my research. It seems to me to point to the fact that, in academic research, knowledge needs to be generated from below and co-produced with – rather than extracted from – local researchers and research participants, to make sure that humanitarian programmes address the real needs of their recipients.

Why did you choose to work on XCEPT?

XCEPT to me was incredibly exciting because it offered an opportunity to work on South Sudan and to expand the knowledge that I already had from working with South Sudanese refugees. It’s also been amazing to be part of such an interdisciplinary team, and to rely again on some of my expertise and skills as a psychologist.

One thing I’ve found really valuable is being able to work so closely with local researchers in South Sudan, to get an idea of the context they are embedded in and to learn more about how they understand their country’s situation. I feel incredibly grateful that we’ve been able to find the people that we did, and they all bring such diverse expertise, commitment, and nuance to the job. The highlight of my work on XCEPT so far has been to spend time in Juba collaborating with the South Sudanese researchers. When designing the research, we tried to construct questions that were really attuned to the context in South Sudan, but when we discussed them with the researchers, we were confronted with the amount of our own inaccurate assumptions that had shaped the questions in the first place.

For example, the researchers explained that questions around causes of violence in instances in which killing had taken place may only be relevant if they were about the accidental killing of a person perceived as innocent. If the killing was a form of revenge, then the ‘victim’ would be seen to be deserving of that kind of punishment, which has enormous implications for how we conceptualise justice and reconciliation in South Sudan. By working together with the local researchers, we were able to deconstruct our questions and rebuild them in a way that will make more sense to the people that will be answering them.

A sign in Palabek settlement encourages refugees to seek mental health support at the local health centre. Credit: Costanza Torre

What do you hope the XCEPT project will achieve?

There are such incredible people working on our team, both in the UK and in South Sudan, and so I hope that our research will be able to provide a nuanced understanding of lived experiences of conflict. When we talk about mental health using a symptom-based model, it can lend itself to the victimisation of people that have lived through violence. By conducting research in a way that closely

involves people on the ground, I think it reopens the space to talk about the human experience of conflict, which can often be a story of enormous resourcefulness and strength.

Ultimately, I’d like a really strong emphasis to be put on addressing the things that actually matter to people. I’d like XCEPT to be able to give recommendations, to the FCDO or any other international organisation with power to implement change, that priorities should be chosen from the bottom up, and interventions should be based around what matters to people in their lives.