4 interventions to help victims of trauma find hope and dignity

Josh Goldstein_keynote speech

Josh Goldstein (CFI) gives a keynote speech at the 8th Annual PCAF Pan-African Psychotrauma Conference in Nairobi, Kenya, a multidisciplinary event that focuses on psychological trauma in Africa’s war-affected societies. Photo: Josh Goldstein

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Read the full text of Josh Goldstein’s keynote speech.


>>Josh Goldstein, Vice President, Economic Citizenship & Disability Inclusion, The Center for Financial Inclusion at Accion

“Over a sixth of the world’s population has directly experienced armed conflict, torture, terrorism, sexual and gender-based violence, ethnic cleansing or genocide.”
— The Peter C. Alderman Foundation (PCAF) website

I recently attended the 8th Annual PCAF Pan-African Psychotrauma Conference in Nairobi, Kenya, a multidisciplinary event that focuses on psychological trauma in Africa’s war-affected societies. PCAF operates mental health clinics in Cambodia, Kenya, Liberia, and Uganda and conducts trainings for mental health professionals. At the conference,I was surrounded by global leaders from health care, academia, and a litany of organizations working in the mental health space.

At first blush, my placement at such an event might seem odd as my work focuses on disability inclusion for microfinance. But, I’d argue that’s more of a reflection of how society, and our industry, views mental disabilities — with reductive biases — rather than how they fit within microfinance.

I had the privilege of presenting a keynote to the attendees. I discussed whether it’s possible for trauma patients who have gone through a successful course treatment that includes counseling, medication, and livelihood trainings to become clients of microfinance institutions (MFI) and build small-sized enterprises. Immediately below is an abridged version of my speech, with the complete text linked at the end.

Can MFIs help victims of trauma find hope and dignity through self-employment?

Josh Goldstein_keynote speech_portAs a post-traumatic stress disorder (PTSD) survivor myself from the U.S., who received treatment, I believe with all my heart that in a just society poor people with mental health challenges should get the help they need so they can flourish as human beings. Unfortunately, in the international development world I come from, this great cause is barely on the radar — in spite of the fact that reaching the most destitute is at the urgent core of all international development work. Indeed, I share your outrage at the paucity of funding and support for community mental health from governments and foundations.

But, why self-employment for those with mental health issues like PTSD? Why not go find a job and work for a business that provides a regular paycheck? Isn’t that easier and more secure? Of course it is. Most clients of MFIs are what we call “necessity entrepreneurs” and would rather have such jobs than start their own businesses. But, the sobering reality of limited formal sector employment opportunities across Africa makes finding such jobs for persons with physical disabilities, let alone psychosocial disabilities, even more challenging than it would be otherwise. Even in my country, the United States, unemployment of persons with disabilities in the formal workplace remains unconscionably high.

But are such financial products like credit or savings a good idea for someone with PTSD? For example, would the effort to save or borrow money bring greater stress? There is no easy answer based on my cursory review of the very limited research studies to date — the results are ambiguous and prove nothing conclusive one way or the other. What we do know, thanks to PCAF Uganda Program Director Dorothy Kizza, is that relapsing back into mental illness is often caused by a lack of employment. So, on balance, the stress of not working may be equally or more stressful than paying back a working capital loan which at least holds the promise of a more hopeful future. My own hunch is that the answer will only be decided on a case-by-case basis and so no generalization is really possible.

What seems beyond doubt, as Crick Lund, a professor at the University of South Africa and CEO of PRIME, a consortium of research institutions and ministries of health, has written, “is [the] growing international evidence that mental ill health and poverty interact in a negative cycle. This cycle increases the risk of mental illness among people who live in poverty and increases the likelihood that those living with mental illness will drift into or remain in poverty.” A big-picture study from the Harvard School of Public Health and the World Economic Forum estimates that the cumulative global impact of mental disorders in terms of lost economic output will amount to US$16.3 trillion between 2011 and 2030.

I am happy to say that the Center for Financial Inclusion (CFI) and its allied partners working on disability inclusion have begun to demonstrate significant success in including persons with physical disabilities in microfinance in Bangladesh, Ecuador, India, Nigeria, Paraguay, and Uganda, and I hope we can expand this initiative to include persons with mental health issues.

However, achieving the progress needed to financially include people with physical disabilities is not the same as that of including people with mental health issues. Persons with psychosocial disabilities in Africa and in many other places in the world are, in the words of Nigerian healthcare advocate Ifesinanchi Sam-Emurwa, “doubly stigmatized” for having a disability and for that disability being a mental one.

And, to paraphrase remarks by Columbia University psychiatrist Dr. Evaristo Akerele, who spoke this past June at the only mental health session on psychosocial disabilities at the U.N. Conference of State Parties annual disability conference: The person with mental health issues is blamed for bringing what psychiatrists call depression, or anxiety, on themselves. Beliefs such as that God is upset with them, that drug use is to blame, that witchcraft is at work, are all common. In most places, the term “depression” is not culturally acceptable or even understood; there is not an accepted and shared nomenclature for describing mental suffering.

An interesting example of how this “double stigma” plays out also comes from Nigeria, in the financial services arena. The Central Bank of Nigeria recently earmarked US$20 million to financial service providers to make loans to persons with disabilities — a great step forward. But, it explicitly excluded persons with mental health disabilities as recipients of these loans.

So, what can be done to improve the situation? I want to suggest five of the biggest challenges we face and interventions that I believe we can undertake together to answer these challenges and improve the livelihood possibilities of persons with psychosocial disabilities. I hope this will form the beginning of an action plan.

Challenge 1: How can the staff of an MFI with no training in psychology even begin to identify clients with mental health issues if there are no common, agreed on terms of reference for describing distressed states of mind? How do we sensitize staff to work with this client segment?

It is relatively easy to determine a baseline of the numbers of persons with physical disabilities who are clients, by asking medically non-invasive questions (or just through observation) about their state of wellness. Unless a person with mental health issues self-discloses, it is impossible to know if they are suffering from a depressive, anxiety, or other disorder.

Intervention: Volunteers from the mental disability space, like attendees of these annual PCAF Conferences,can help financial service providers design survey questions that allow MFI staff to get a better count of current clients with mental health issues. These volunteers along with PTSD survivors themselves can help sensitize MFI staff on how to best reach out to persons with mental health disabilities. They can connect MFIs with community mental health leaders and, in particular, patient advocates. These learnings can then be incorporated into the Framework for Disability Inclusion so that a set of best practices can be developed and shared with MFIs from around the world.

Challenge 2: Access and support for basic capital and business training for persons with psychosocial disabilities is largely lacking.

Intervention: Connect PCAF graduates, and those of other mental health clinics that include business training, to microfinance providers, credit unions, self-help savings groups, and otherproviders offering group-based financial services as well as enterprise-building support to professionalize the business training and operations of the clinic patients. The natural intermediary to make first contact with the MFI or other provider might be the PCAF social worker, during their weekly or monthly follow up outreach to former PCAF patients in their villages, homes,and workplaces.

Just as CFI identified two or three institutions in India that were eager to do a pilot to include persons with disabilities in their programs, we can work to identify two or three MFIs in the PCAF countries of Cambodia, Kenya, Liberia, and Uganda who want to be leaders in including persons with psychosocial disabilities in credit and/or savings groups. Success is promising here since a portion of PCAF livelihood trainings are done in groups,suggesting that the transition to group lending methodologies could prove to be quite natural and comfortable.

Challenge 3: The United Nations (U.N.) does not do enough to recognize the importance of mental health disabilities — when it comes to collecting good statistics, when it comes to prioritizing it as a Sustainable Development Goal to reduce extreme poverty, when it comes to seeing therapeutic intervention as a significant part of the Constitution on the Rights of Persons with Disabilities treaty.

Intervention: Those working in this field and other interested parties should lobby the Washington Group on Disability Statistics (the U.N. body charged with disability statistics) to include a specific question on mental health in its so-called “short set” of questions that it provides to governments that do censuses and disability surveys. Similarly, while they’re still being shaped, pressure should be applied to modify the Sustainable Development Goals to include much stronger language on mental health.

Finally, there must be concerted lobbying by PCAF, and others, to ensure that in implementing the articles of the U.N. Convention on the Rights of Persons with Disabilities, the right to receive treatment for mental health ills gets equal billing with assuring the right to vote and enjoy equal protection before the law. If this does not happen, it will be much harder for mental health practitioners to obtain funding from governments and foundations to expand their community mental health programs — something critically important in countries like Burundi that have only one psychiatrist in the whole country!

Challenge 4: To create a new set of global standards and indicators for microfinance institutions and other financial service providers to follow that will establish the importance of and offer guidance on serving PTSD survivors and other persons with psychosocial disabilities.

Intervention: The CFI will work collaboratively to push the microfinance industry-wide standard-setters to add mental health indicators. With the help of key industry standard-setting groups, I believe that we can help to break down the attitudinal barriers that keep persons with psychosocial disabilities in extreme poverty unbanked and stigmatized. For example, I am delighted to announce that the Poverty Stoplight has offered to take the lead in creating a mental health indicator for its assessment tool. The Poverty Stoplight set of indicators, pioneered by Fundación Paraguaya and now used around the world, sees poverty as multidimensional and have developed a tool that allows the poor to measure their own poverty, broken down into different categories. Adding a mental health indicator could be a source of data that could be used not only by MFIs but by local community mental health leaders and other public health providers.

Freedom from Hunger in conjunction with the Microcredit Summit Campaign has just published a new guide called “Healthy, Wealthy, and Wise: How Microfinance Can Track the Health of Clients,” in which they share experiences in selecting and pilot-testing health indicators among four MFIs. The researchers asked questions around six health indicators: food security and nutrition, preventive health care, poverty, curative health care, sanitation and safe water, and attitudes. The results demonstrated the added value of health indicators when combined with poverty measurement in helping MFIs understand client well-being. Their “theory of change” is that with greater financial resources, the clients will be able to meet their essential needs as outlined above — like having cleaning water or improved nutrition. I have consulted with the guide’s author, Bobbi Gray, and she is very willing to work with us to see if we can help her develop a seventh indicator around mental health — which is great news.

My conclusion is that self-employment can offer dignity and hope to persons recovering from mental illness. And, that like persons with physical disabilities, many can make excellent clients. I think it is worth exploring how we can do more to connect to PTSD survivors with MFIs and other financial service providers to open their doors to PCAF clients and those of other clinics. At the very least, this initiative will help fight stigma and bring down attitudinal barriers. Let us see what works and what sticks. It is certainly worth a try.

Read the full text of Josh Goldstein’s keynote speech.


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2 thoughts on “4 interventions to help victims of trauma find hope and dignity

  1. Pingback: Mental health matters for microfinance | 100 Million Ideas

  2. Dear Josh, first of all, thank you for mentioning the health indicators work we’ve been exploring with various MFIs around the globe. Some of our initial testing around mental health indicators has been limited and was initially driven by the acknowledgement that consequences of domestic violence should be better understood and tracked. Indeed, when we began researching and understanding this better, by using Demographic and Health Surveys, we found that in many of the countries we work, the prevalence of domestic violence is fairly high, often between 20-50% of women experiencing domestic violence. So we began to explore this topic a bit more, and obviously, mental health issues around domestic violence are just one slice of the pie here.

    In the past two years, we’ve conducted research in Burkina Faso with 46 women that we followed over a 7-month period to understand resilience. We tried to look at “resilience” holistically and included “attitude” questions in all 10 surveys we conducted, and then one entire survey focused on attitudes and perceptions of one’s life. We pulled heavily from research conducted by Johannes Haushofer, who is a professor/researcher at Princeton. (The Price of Poverty: Psychology and the Cycle of Need. Foreign Affairs (2014), 138739.). He took variables from a world values survey and compared these to poverty status. In the research in Burkina Faso, we compared self-perceived resilient status (basically, based on what you consider to be a resilient household, do you believe your household is resilient) to a series of indicators, approximately 14 of which were attitude/perception indicators. We found that those who considered themselves resilient, were also likely to report feeling supported, hopeful, capable of meeting one’s financial obligations, trustful of others, not living one’s life “day to day”, and reporting they would try anything to improve their life. There were several attitude questions that weren’t associated with resilient status, but our sample size is small, and we’d never assume all of the indicators we looked at would necessarily be associated. (This research will be available by the end of October through CGAP).

    At this point, I’m not exactly sure which measures will turn out to be the most relevant and useful in all the contexts where we all work, but this is just an example of some indicators that are a good starting point for generally understanding a person’s perception toward their own life. Given Haushofer’s research and our simple forays into choosing indicators that we think microfinance organizations can measure and use to monitor client status, I think we’ll all have a greater appreciation of the power that positive or negative mental health can have on a person’s productivity and likelihood of success with the types of financial tools we can provide. One result that really struck us in our resilience research is that people’s attitudes tracked very closely with their food security status, such that when they were most food insecure, they had the poorest outlook on their life and future, but as they came out of a the hunger season, their outlook improved.

    I think a lot of the research is there that already suggests that mental health matters (even if we’re not distinguishing between people with diagnosed mental health impairments versus assuming that if a person is poor, they are likely also suffering from mental health challenges.). This may be a good starting point, by simply assuming that mental health in general matters for all current and potential clients of microfinance institutions. Maybe this is why we all feel so struck by the importance of creating “hope” in the people we work with, because it can be a powerful attitude/perception that can be built upon. A person feeling hopeful has the energy to keep moving forward.

    The challenge or opportunity we have, is to begin to value indicators that are often considered “soft,” like mental health and people’s attitudes/perceptions towards their life compared to the traditional “hard” indicators we typically value, such as loan size, savings amounts, revenues, profits, etc. I actually feel quite confident in getting to a place where we have effective indicators, because it’s a simple matter of testing, valuing the data –I think the harder piece of this is designing the services in a way that don’t create mental distress or that help people with mental health impairments invest and succeed at businesses.

    I think we’ve all had periods of our life that we can relate to what mental distress feels like – your bandwidth is limited and it’s hard to feel hopeful when you’re going through a trial. I wonder if we should assume that the starting point is that all clients we serve could benefit from mental health support given what we know about the psychology of poverty. This way, it’s not about diagnosing people to determine whether a product is right for them or not, but assuming that everyone deserves a financial product/process that helps people through life’s short and long-term crises –whether it’s a visual health crisis (cancer) or a mental health crisis. Obviously, this is easier said than done. But over time, I’ve come to really value and appreciate what the mental health/psychosocial indicators can tell me about a person’s life. Even if a person’s poverty status hasn’t changed, but their belief that their life is better and more manageable, I can see where that can be considered success.

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