Invisible Scars in a Time of Crisis
In war we see local health facilities destroyed, health care providers fleeing for safety, and of course many people being injured by bombs and bullets. But beyond the physical ailments, there are some wounds that are unseen, scars that are invisible to the eyes.
Although Médecins Sans Frontières/Doctors Without Borders (MSF) had been providing emergency medical care to people in crisis for over 20 years, it was only in the killing fields of Bosnia in the 1990s that MSF field workers recognised that it was not enough to meet the physical needs of people caught up in conflict. The psychological and emotional scars of war – wounds that may continue in people's minds long after the fighting has ended – were being neglected and must be addressed.
The emotional and psychological distress of people caught in crossfire or the agonizing loss of family members due to an earthquake can be a major health concern if neglected.
Since the Bosnian war, MSF has conducted mental health interventions in many countries and in different settings – beyond refugee camps, war and natural disasters, they are also given to patients living with HIV/TB, for victims of sexual violence, and in other medical activities.
In 2012 alone, MSF teams across the globe conducted more than 169,000 individual mental health consultations and over 21,000 sessions or group counseling.
MSF's mental health workers provide psychological education and train local counselors to assist in their communities. They establish walk-in clinics but also bring home-based care to people too traumatised to leave their homes.
Very often medication is not required for psychological trauma. With the right guidance and teaching of simple coping mechanisms, people can make great gains in dealing with fears and anxiety and can restore their normal day-to-day functionality.
The patients MSF see vary - sometimes just one session is enough; some people just need to hear that what’s happening to them is normal, that they are not going mad. But there are also other patients that need counseling for longer. The idea is to set a clear objective with them, and to get there step by step with behavioral therapy.
In many cases, those suffering from depression or anxiety never seek treatment or help. But the experience of Audrey Maggis, MSF psychologist who spent two months in Syria, tells the opposite story.
“In most places I have worked, people are rather hesitant when I tell them that I am a psychologist. But in Syria, it was quite the opposite. People actually came and told me they needed my services. The war has been raging for two years and people have completely lost their bearings. At first, they would come and tell me about their social problems at home. But when you dig a little, you quickly find that most have experienced deeply traumatic events. Some have lost friends or family. Some have seen their home destroyed. Some have lived through bombing raids…”
Our long experience now of operating mental health programmes from Africa to the Middle East and southeast Asia means that the design of interventions take account of cultural differences. For example, MSF field workers found the greatest success using group therapy for people affected by the civil war in Sierra Leone. But during the war in Chechnya in 1995, people were reluctant to speak within groups and favored one-on-one sessions in formal health structures. In Iraq, telephone help-lines have been set up in two areas for patients who want more information or cannot access the counselors in person.
Psychological distress can be hard to identify when it manifests itself as physical pain. Typically there are patients who complain of unspecific pains or who come back several times and the doctor could find nothing wrong. These patients are referred for counseling. So often, the grief is so deep and traumatic for these patients that it becomes physical - one reason why it is so important to integrate the management of mental healthcare into other MSF’s medical activities.
Counseling may not be able to replace medications but it makes a difference in the lives of people in crisis.
by Remi Carrier, Executive Director of MSF Hong Kong
