Here is a situation that’s happened to me; maybe it’s happened to you, too. You’re on mission, finishing up a meeting. You’re closing your notebook, your head’s in the next meeting already, and one of the people you’ve just met with asks if you have a second.
Before you can react, she’s telling you her story. It’s a very difficult story, full of experiences you can’t imagine living through yourself. She seems to have gone back into the story in her mind – her eyes are focused beyond you, her hands tremble, and her eyes water.
Assuming you are not a trained social worker, it’s likely you have few skills you can immediately draw on to help her. And you wonder how many others like her are facing similar circumstances.
What does any of this have to do with our business? Our work brings us into contact with people and groups that have experienced extremely stressful events and situations – from grinding poverty, to forced displacement, war and natural disasters. We come into contact with some of the most wounded and most resilient people in the world. While that strength helps them survive in the face of huge challenges, these “invisible wounds” – if not addressed – take a huge toll on them and their loved ones.
We see the manifestations of these “invisible wounds” in our projects. An ex-combatant may lose his temper – and his place in a reintegration program – if he is triggered by a reminder of his time in the war. A woman may stop participating in a project after seeing the man who sexually assaulted her – or someone who looks like him - at one of the meetings. Civil servants working in temporary buildings after an earthquake may find it hard to concentrate amidst fear of another natural disaster. A family displaced by violence or natural disaster may find it hard to risk taking out a microcredit loan, given the daily uncertainties they face.
The impacts of these stresses add up. According to the Global Burden of Disease study , mental health disorders – often the result of or exacerbated by traumatic experiences – represent a larger disease burden than HIV and malaria combined, and depression is the leading cause of disability worldwide. People living with acute mental illnesses such as major depression and schizophrenia have a 40-60 percent greater chance of premature death than the general population, either by physical illnesses (such as cancer and cardiovascular disease) that go untreated, or by suicide. Among young people, suicide is now the second most common cause of death, after car accidents.
The effects of stress and trauma extend over generations. Studies from various countries have shown that people exposed to traumatic experiences run a greater risk of poor life outcomes including compromised physical health, risky behaviors like dropping out of school or substance abuse, poor economic self-sufficiency, or poor parenting skills for the next generation. New evidence from the field of behavioral epigenetics suggests that traumatic experiences may even be transmitted biologically across generations, passed down to children along with the memories that are recounted about those experiences.
We are a development bank, not a trauma healing or mental health institution. It is unlikely we would be able to put a trained social worker on every project where trauma is an issue. But there are things we can do – and are already doing – in our projects to improve our response to those who have been through difficult events. Various Bank demobilization and reintegration programs have addressed trauma of ex-combatants through psychosocial support; in Rwanda and Somaliland, these have included training in microenterprise development, home visits and counseling, and community and family sensitization trainings. Specialized therapeutic services have been added to economic empowerment projects for survivors of sexual assault in post-conflict contexts like Ivory Coast and DRC, as well as post-disaster contexts like Haiti, with positive results. A youth employment project in Sierra Leone has implemented a Youth Readiness Intervention (YRI) component that helps youth develop skills to regulate their emotions and deal with stress positively, and preliminary results suggest that youth who receive this support are more likely to stick with the program and perform better.
Trauma and psychosocial well-being are part of our business. The current Bank reform process provides us with an incredible opportunity to address issues of trauma and psychosocial well-being in a holistic, multi-sectoral way. Already, there is a growing conversation within the Bank on this; see for example Patricio Marquez’s recent blog, Mental Health: Time for a Broader Agenda , on the need for development actors to engage more directly on mental health issues.
Our Social Cohesion and Violence Prevention Team is building on this by hosting "Invisible Wounds": A Practitioners' Dialogue on Improving Development Outcomes through Psychosocial Support  on May 6 at World Bank headquarters, convening a group of experts from disciplines ranging from neuroscience to education and youth employment. Please join us if you want to be part of the conversation about how we can make our project both more inclusive and effective, by addressing issues of trauma and psychosocial well being. Let’s keep the conversation going.
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Artwork by Andy Jefferson titled “The Heavy Load”, 1995, part of the World Bank's Art Collection
See also Patel, V, Flisher AJ, Hetrick S, Mcgorry P “Mental health of young people: a global public health challenge,” Lancet 2007: 369:1302-13.