For migrants lost in the middle of the sea, after fleeing persecution and war, these three words mean all the world.
Helping people cope with the psychological and mental health impacts of crisis.
Charity fled as soon as she heard the gunshots. “I could feel the bullets hitting my flesh,” she says, recalling the day last year when armed fighters stormed in to her village. “I could see people falling when I turned around. One of them was my husband. I saw him fall, but there was nothing I could do.”
The 36-year-old mother of seven found safety in a camp set up by the United Nations in the city of Wau, South Sudan. But she was haunted by that violent evening. “For a long time, I could hear the sound of bullets in my mind,” she says. “Bam, bam, bam. All the time. It felt like a nightmare and I heard the sounds, even if there were no gunshots around.”
While Charity still suffers great sadness, her pain and her symptoms have eased somewhat due to counselling sessions managed by a local organization called the Women Development Group (WDG). Supported by the ICRC, the organization’s sessions are a mix of group therapy, activities that help the women generate income and lots of love from Sidonia Paul, a WDG field officer trained in providing group support for victims of violence.
“This support is different from giving someone food,” she says. “A person can eat the food, but the problem will still be there. If you can help someone with their mind, they can learn how to provide food for themselves and their family.”
These ongoing counselling sessions are just one example of how humanitarian organizations are integrating mental health and psychosocial support into their humanitarian responses.
While such support has existed for many years, its provision during emergencies has been relatively ad hoc. Now, some form of mental health or psychosocial support is present in nearly every major emergency, but most experts agree it needs to be expanded and more effectively integrated into crisis response.
“After disasters, people know that we have to provide food, blankets and places for people to sleep,” says Eliza Cheung, a clinical psychologist and an expert in psychological first aid. “But if we do not also take care of their mental health and psychosocial issues, we can never really address their full needs.
“We have seen examples of providing food for survivors but they don’t have an appetite,” says Cheung, an adviser for the IFRC’s Psychosocial Support Centre in Denmark and a psychological first responder for the Hong Kong Red Cross. “We have provided shelter but they cannot go to sleep because of their haunted memories or flashbacks.”
Loss of sleep, paralyzing fear, chronic anxiety. These are just some of the symptoms that can keep people from getting back to normal life. Fadimata Touré, from the Timbuktu region in Mali, was working in her small shop in 2012 when men from an armed group threatened to arrest her for not dressing according to their version of Sharia law.
“Armed men got out of the vehicle and ordered me to go with them,” she recalls. “I was so frightened I began to vomit.”
Local elders who eventually managed to get Fadimata released but a gripping fear lingered. “I had nightmares all the time and was unable to sleep properly. I couldn’t stop thinking about what had happened. I lost my appetite and was on edge all the time. I found it difficult to leave the house; it was as if my life had been put on hold.”
Then she heard that the ICRC was helping people with psychological problems caused by the conflict. So she made an appointment.
“I felt as if she had just lifted a heavy burden from my shoulders,” she says, adding that after several sessions she regained the confidence to restart her business. “I started to go out again and meet people. I no longer had trouble sleeping and the incident wasn’t constantly on my mind as it had been before.”
Mental health and psychological support don’t erase suffering. But even simple techniques such as breathing exercises can help people cope with distress reactions such as nightmares, anxiety or headaches. “They may still have nightmares, but they know what to do to go back to sleep more easily,” adds Cheung.
Experts emphasize that in the aftermath of crisis, it’s not about offering psychological treatment or psychotherapy, in which people delve into the root causes of particular disorders. This kind of treatment would only take place at a later stage, if needed, once the person’s immediate traumatic reaction has subsided or stabilized.
“Getting them to recall the gruesome details of a traumatic experience can cause a secondary trauma,” she notes. “So with psychological first aid we do not dig into these stories unless the person feels the need to do so. In that case, we provide proactive listening and emotional support. If the person does not want to talk, our approach would be to focus on their needs here and now.”
It’s important to keep in mind, she says, that even months after a disaster or crisis, many people are still undergoing traumatic upheaval. After the April 2015 earthquake in Nepal, for example, people had to set up temporary housing very close to their destroyed homes.
“People would pass by the rubble of their old houses every day and would point out, ‘This is the place where I found my dead child. Passing by and seeing it every day makes me really anxious. It takes me back to the exact time the earthquake struck,’” says Cheung.
But how to bring meaningful and effective psychological care, appropriate to the needs, to large numbers of people in places where health systems are inadequate, non-existent or highly disrupted by crisis?
Consider the conflict in Syria. Before the war broke out, the country had a functioning health system that included psychologists and psychiatrists in both public health services and private practice. Now the health system is largely destroyed and most health professionals have fled the country.
For millions of Syrians living under siege, displaced or living in other countries, finding help is extremely difficult. Health systems in neighbouring countries, stretched thin before the conflict, are not able to meet the increased demand. Humanitarian organizations and local non-governmental organizations (NGOs) are working desperately to fill the gaps.
“We do not have enough staff to address these problems, so many people are not being helped,” says Martha Bird, an adviser at the IFRC’s Psychosocial Support Centre in Copenhagen, who is coordinating research on a variety of scalable psychological interventions proposed by the World Health Organization.
“What these interventions generally try to do is change who — which professionals and which people — can offer help. So instead of using highly trained psychologists, Syrian refugees who are not suffering from severe mental health problems can be trained to offer these services. It’s a peer-to-peer model.”
Through randomized control trials with Syrian refugees in eight countries (Egypt, Germany, Jordan, Lebanon, Turkey, the Netherlands, Switzerland and Sweden), the research is hoping to establish whether these interventions work. If they do, the idea would be to bring them to a far wider group.
“Hopefully, it will allow us to address the mental health problems of a lot of people at lower costs and with more people able to do it,” says Bird. “What we have to be very careful about is implementing the intervention with the right beneficiaries. So the intervention precludes, for instance, people who are suicidal. They would need much more care.”
Supervision is also a key element. A typical scenario might involve four Syrian asylum seekers working in an NGO with a fifth overseer who is a Syrian psychologist and a sixth who is a psychologist from the host country. “They would monitor whether the helpers are themselves well and implementing things correctly,” says Bird.
National Societies are also scaling up. Under a cooperation agreement with UNICEF, the Turkish Red Crescent is training young Turkish and Syrian volunteers to work with children in dozens of “child and youth friendly spaces” — established in numerous camps and urban centres — where children can freely and safely express themselves.
According to two psychologists who studied the impact of these efforts, the child friendly spaces offer young people — who have experienced great trauma and continue to live very restricted lives — to be children again.
“Some children have been living in camps for over four years, behind fences, without contact from anyone outside the camp,” the two psychologists wrote in a 2016 report. Those who live in cities, meanwhile, are in poor, overcrowded accommodation, face daily harassment and a very uncertain future.
While the volunteers can not address all these problems, the fact that the Turkish youth workers can speak with the child refugees (in Arabic or in some cases Kurdish) means that at least the children can be heard. The young Syrian volunteers, meanwhile, enjoy an even closer cultural connection. “As a result, the work turns into a healing process for the children and the young people,“ the psychologists reported.
According to the Turkish Red Crescent, some 2,500 volunteers have been trained so far, and some 377,000 children have benefited from the child friendly spaces. Still, the authors conclude that to meet the need, the number of child friendly spaces in camps and urban areas need to expand dramatically.
The authors also recommend that more specialists in psychological counseling and social services be hired. After all, activities and safe spaces, in and of themselves, don’t necessarily address more serious mental heath challenges.
Given financial and other constraints, however, scaling up the response may not lie with humanitarian organizations deploying armies of psychologists or volunteers in every emergency. Milena Osorio, coordinator of mental health and psychological support programmes for the ICRC, says one solution lies in working with local organizations, health services, schools and social-service providers already working in affected areas.
“There are people all over the world already doing a fantastic job but not with a lot of tools or resources,” she says. “We want to give them the tools so they can continue to be doctors, nurses, teachers and volunteers but with more empowerment to address some of the psychological needs people are experiencing.”
With proper training, these local workers can identify which problems they can handle and refer those they can’t to specialized professionals. And because they know the local culture and languages, they are more likely to build up awareness and trust around services that are still very foreign in many cultures.
After all, psychological counselors such as Bakitta walet Bettou, who works at a referral health centre in Kidal, Mali, must often address very sensitive issues.
“Sexual violence remains a taboo subject that people pay little attention to in spite of it being a very real problem,” she says, adding that despite falling victim to many traumas, many local people don’t know about, or have little faith in, psychological counselling.
In this context, psychological care from a trusted source can save lives. When a patient recently suffered a grave injury to one of his legs due to an explosive device, the ICRC surgical team asked Bettou to help persuade the patient to agree to having the limb amputated.
“It is never easy to make someone understand that they have to lose one of their limbs, but I did everything I could to convince him to take the right decision for his own wellbeing. After the operation, I provided him with psychological care.”
One of the greatest impediments to reaching people with appropriate care is the stigma that comes with it. People don’t understand that what they are experiencing is normal given what they have been through.
A 28-year-old mother living in Switzerland, Ruken Hüseyin,* often has panic attacks when she leaves her quiet neighbourhood. An ambulance siren or an accelerating car can take her back to the worst hours of her life.
Fortunately, she became aware of services for people who have been tortured or affected by war offered by the Swiss Red Cross. In a group therapy workshop for women, surrounded by recent migrants, asylum seekers or refugees from Eritrea, Sri Lanka and Syria, she felt understood. “For the first time,” she says, “I think I may not be crazy.”
But there is nothing ‘crazy’ about Hüseyin’s reaction. “It would happen to anyone,” says the ICRC’s Osorio. The problem is that in many cultures there is an intense stigma associated with both having psychological weaknesses and seeking treatment.
“It’s one of the few problems where if you look for help, it’s not seen as doing something good,” she points out. “So it’s very challenging to, on the one hand, live with the problem and, on the other hand, receive help.”
Changing mindsets therefore is critical, she says. “If it becomes less difficult to say, ‘I need help and I’m going for it,’ then all these people who are suffering in silence may go and get the help they need,” she adds.
One of those people was 30-year-old Hana El-Ali from Halab, Syria. She and her family fled extreme hunger and fighting in Syria and found refuge at a camp in Lebanon. Deeply affected by her experiences, she was in “a terrible psychological condition,” she says. Shut down and underweight, she lost her ability to cope and even to laugh.
“I was living among other people but only my body was there. I couldn’t sleep. As soon as my eyes closed, I woke up immediately, always worried. I tried to cry but couldn’t, the tears just wouldn’t come out.”
For some time, fear of judgment from family, friends and neighbors kept her from seeking care. With support from her husband, she garnered the courage.
“At first people were saying, ‘she goes to the psychiatrist, she must be crazy,” she said. “But I explained that you don’t have to be crazy to go to the doctor.”
What finally convinced them was the change they could see with their own eyes. “I put laughter back into my life, I resumed playing with my children and going out,” she says.
Emergency workers also need psychological and emotional support. “Most [psychosocial support] interventions or programmes target the general public and we forget the people providing the services — the volunteers,” says Kinan Aldamman, a clinical psychiatrist and formal psychosocial coordinator for the Syrian Arab Red Crescent.
“Both volunteers and the people they are helping are part of the same community,” says Aldamman, who is doing a doctoral thesis at the Trinity College, Dublin, on the psychological needs of volunteers based on his experience in Syria. “So the volunteers are experiencing the same stressful things that the community is facing. Yet the volunteers are asked to be compassionate towards people and provide services with very limited resources.”
After seeing the effects of that stress first hand, Aldamman helped create a peer-support programme along with the ICRC in which Syrian Red Crescent volunteers are trained to offer basic psychosocial support to their colleagues.
Aldamman hopes his studies, supported by the IFRC’s PSS Centre, will help Red Cross and Red Crescent National Societies improve their own volunteer support systems.
“First-aid volunteers provide physical first aid after an attack or an explosion, which they are trained to do, but they also provide psychological first aid, for which they often lack training,” he says, adding that this can cause additional stress on the volunteers.
“They have a strong feeling of responsibility towards the survivors so they sometimes get too deeply involved in their stories, which makes them vulnerable to vicarious trauma or other extreme stresses.”
Slowly, the humanitarian sector is waking up to the great need for mental health and psychosocial support for all people affected by crisis. Avril Patterson, who worked as health coordinator for the ICRC in Syria for four years, says that attention is long overdue.
“We need to look at mental health as part of emergency response,” she says. “We need to integrate it from the beginning. If you see someone struggling to stand up, you don’t wait until that person falls over to offer them a seat.”
For migrants lost in the middle of the sea, after fleeing persecution and war, these three words mean all the world.
Are tsunamis in Hollywood films realistic or pure fiction?
Mental health and psychosocial services can be critical to recovery efforts in times of crisis.