Working in Humanitarian Settings as a Mental Health Professional
I write this blog to celebrate World Humanitarian Day 2015 and the invaluable work of humanitarians throughout the world.
When I think about humanitarian work, the principles of Psychological First Aid come to mind e.g. humane, supportive and practical. I can imagine the many health workers who have captured this in their work in such difficult environments.
My main role has been to train field workers and it has been a privilege to meet so many people actually working front line with those in need. These people are the heroes. In my mind I remember the workers but not always where they are. What is common to them is the suffering in mental health and overwhelming need. The stories I hear, vary by place and situation – war, Ebola, poverty refugees, HIV, gender based violence.
In this blog, I will write about a few different places where I have worked in the past few years to give a flavour of the experiences and work of the humanitarians in the field.
I was in Iraq in 2013 and 2015. During my first visit, we delivered a mhGAP training to psychiatrists from all over Iraq. More recently, we acted in response to the humanitarian crisis of Syrian refugees and Iraqi internally displaced people due to the Islamic State (IS).
The extent of the problem is vast. The number of refugees and internationally displaced persons (IDPs) is enormous and increasing all the time. I had worked in refugee camps before, but these camps were fresh, raw and pained.
My main role was to train field workers using the mhGAP Humanitarian Intervention Guide. We were in Kurdistan specifically about 30 minutes from the IS territory Mosul - we were very aware that a wrong turn could be catastrophic. I met many professionals who had been forced to move as a result of IS and it was clearly very painful for people to speak about these experiences. I could relate to these people who were fellow doctors or psychologists who were now devoting themselves to humanitarian work for their people.
We had two main trainings in Kurdistan. The first was in Dohuk which is close to the Turkish border. There is a large Syrian refugee camp there with almost 50,000 people. This place reminded me of refugee places I had been to elsewhere. One could feel that people were settled in the camp and had given up on hope of return to their homes or getting out of the life they now knew, or in other words, were facing a resigned depressive state.
The other camps we saw were for the Yazidi people fleeing IS. This was a harrowing place. The arrivals to this camp were new and had numerous stories of death, rape and religious cleansing. Whilst meeting the humanitarian workers, it was clear that they were providing humanitarian support for distressed people however were so close to their own breaking points. Some of the humanitarian workers had been imprisoned before coming to the camp. I remember one case in the Yazidi camp of a man who had lost multiple members of his family and seen terrible things. I was unable to say anything to him as his story was so appalling. Yet he was being seen by the Yazidi and other doctors and given care.
We covered stress disorders particularly as this was what everyone was living with day in day out. Two years before, I only heard stories of explosions and violence during the trainings in Iraq. Now it has gotten worse in Iraq and Kurdistan.
A few of the cases I saw in Iraq:
- An 11-year-old child suffering from sleeping problems, fear, crying, depressed mood, involuntary micturition, and difficulty in concentration, all PTSD symptoms as a result of seeing people who had died, during his family’s displacement from Syria. He also had his own life threatened many times and has been exposed to many situations like family abuse since displacement.
- A 25-year-old woman having problems of hysterical attacks and is suicidal.
- A 70-year-old Yazidi woman exposed to shock and fear due to violent displacement by DAESH. While injured, she was transported by a tractor which increased her levels of suffering both physically and psychologically, in addition to the fear she already lived in as she was among those who was displaced quite late. Now she is living with a lot of stress and anxiety in addition to physical pain and she is unable to speak.
- Two months ago at a PHC centre, a 20-year-old young woman presented a sudden loss of vision of both eyes after she lost her father in a war between Peshmerga and ISIS. After taking her history and excluding physical attributions, I realised that it was most likely a conversion disorder. I used “respect attitude” and she was better within an hour.
Recently, a Syrian Psychiatrist that I have known for many years asked me to deliver a mhGAP training in Turkey for Syrian refugees. I trained 24 psychiatrists, nurses, and psychologists who were working with Syrian refugees in the border areas of Turkey.
Here are some of the cases that participants described and I don’t think I can give a better feel of what is happening on the ground than these examples:
- A 35-year-old female with symptoms of insomnia, anorexia, aggressiveness, anger, becoming more isolated as her symptoms become worse. She has bad dreams and bad memories and hits her children. She also doesn't want to speak.
- A 27-year-old single lady who is the youngest of 3 siblings. She was engaged for six months when her engagement ended two months ago. She now not eating and is harming herself. She also has menstrual irregularities.
- A 40-year-old man in a state of psychic shock because he has seen many people who died after a barrel bomb fell on a building near him. Since then, he has nightmares, shock and increased startle response.
- A 35-year-old single man who is survivor of torture. He has partial physical disability and the main presenting problems are insomnia, flashbacks, emotionally sensitive, hopelessness, multiple somatic complaints, suicidal thoughts, and sexual dysfunction.
The participants were very committed to their work and were sincerely dedicated and passionate about helping the Syrian refugees. It was more than people just doing their job.
There was a lot of anger directed at the war situation and whilst I can understand these views, there is also a cogent argument on the other side as well. What is common is the suffering that war causes and that these humanitarian workers are committed to alleviating human suffering.
Furthermore, we also learn that mental health is one of the most disabling conditions on all sides of conflict and that people living in these conditions are often in a continuous and ongoing state of stress with no clear end in sight.
The King’s College Somaliland partnership has been operating in Somaliland for a number of years. Through this partnership, we have delivered a mhGAP passed curriculum to undergraduates for about three years.
We used the mhGAP with some supplementation to include causes of diseases and psychiatric emergencies. We also had to bring in Khat (or Qat) as the main drug of abuse and also mention alcohol unexpectedly given the culture we are talking about. 60 people were trained in these skills.
As I have been doing this since 2008, I know many of the doctors working in the country. Mental health remains a big issue in this region. Some of the doctors find themselves in very remote places and are often the only source of mental and psychosocial support in the whole area.
We will continue to support our partners there working in a situation of very poor resources and conflict.
I have the ability to come in and leave as projects arise and finish. However these health workers do not have the luxury, and continue to live through the suffering every day and even then manage to cope in some way.
I end this blog by asking everyone to remember these heroes that work in such difficult environments. I am able to leave and return to my safe life in UK but these people face ongoing adversity and still continue their humanitarian work.
Dr Peter Hughes is a Consultant Psychiatrist Springfield University Hospital London, Chair of Volunteering Special Interest Group at Royal College of Psychiatrists, a mhGAP Trainer and Lead for Mental health Kings Hospital Links to Sierra Leone and Somaliland.
Photo Credit: © 2009 Mukhtar Ahmad/REFAH AID, Courtesy of Photoshare