A Psychosocial Response
Dr. Nancy Baron / May 10, 2008
Medical personnel and people working NGOS in Cairo who are meeting Iraqi refugees often speak about their need for “psycho-social counselling” because of the terrible events these people have survived. Dr. Nancy Baron, is an American Psychologist/ Family Therapist with 15 years of experience assisting war affected populations in Africa, Asia, Europe and the South Pacific cope with their experiences. She is currently in Cairo consulting to AMERA, Terre des Hommes and the American University in Cairo. Here are her thoughts about the needs that Iraqi refugees may have for “psycho-social counselling”.
Journalists today repeatedly talk about populations as being “traumatized” by war. As a mental health person, I would never say “traumatized.” That suggests mental disorder and I would never suggest that a population of survivors is ‘mentally disordered’. Why put the stigma of mental disorder on an already victimized population? Research on the mental health of people in countries suffering from wars and disasters actually shows that few people become seriously mentally ill due to their experiences. Most often survivors are resilient and use their available resources to cope.
An international set of guidelines to direct the design of psycho-social and mental health programs for emergencies was recently developed. It states that there are multiple levels of intervention needed for the multiple layers of problems.
Interventions for people with serious mental disorders (like psychosis where they have lost sight of reality or have a severe depression and are suicidal or anxiety that prevents them from completing their daily life tasks) is needed by 1%-5% of an emergency affected population. In any population around the world even without an emergency, 1%-3% of the population have serious mental disorders. This only increases by 1%-2% during an emergency. Though only a small segment of the population, the need for proper medical care and medication at this layer is extreme. Without this care, those who need it are seriously vulnerable to death and abuse.
Supporting the mental health of refugees is not only about providing the most seriously disturbed with professional mental health care. In designing a “mental health” program for refugees it is important to do an assessment and understand the actual problems, needs and available resources before jumping into starting a program.
Support to mental health actually begins with relief. During and after an emergency, the first and largest layer of service needed by refugees is relief assistance for food, shelter, security and health care. We have all seen on television what happens when poorly trained relief workers throw food at hungry, desperate refugees and watched as relatively calm human beings become wild animals in their fight to survive. Relief assistance that supports human dignity and self-respect is essential to refugees and promotes their mental health and helps to minimize their feelings of hopelessness and distress.
To support their mental health, refugees require that their basic psycho-social needs are met. “Psycho” refers to feelings and emotions and “social” to social relationships and interaction with family, friends and the environment. Living in a safe environment, with basic needs for survival met and surrounded by the emotional care of family and community supports the mental health of refugees.
Despite the difficulties of their lives, most refugees never develop serious psycho-social problems. As example, a refugee man who lost his wife lives in a camp with his children. One man lives with his sisters who share the care of his children while he goes out to find work. His life is a struggle but he copes with the support of his sisters. Another man in the same situation has no family and starts to drink alcohol excessively and begins to abuse his children. This man has a psychosocial problem. It was not caused by being a refugee or losing his wife but rather by his inability to cope.
As a general rule, most refugees find ways to cope. Human resilience is incredible. Refugees use their “protective factors”, the most important of which is their social support net works to help them to cope. If two refugees experience the exact set of horrors, one might cope better than another due to the availability of social support. “Refugees with family and/or community members to emotionally support them will generally do better than refugees who have no one.” As example, a woman who has been raped but has the support of her family and community who believe that it wasn’t her fault and still love her will do much better than a woman who goes back to a community where she is stigmatized and condemned and loses all rights. The availability of a supportive social support network makes a huge difference in adjustment and coping.
The meaning behind difficult experiences also has an influence on the ability of refugees to cope. As example, a person tortured and in a prison cell due to strong beliefs or a cause will usually cope better than someone imprisoned and tortured falsely.
Family and community care is most often the best support for people with psychosocial problems. About 10% of the population needs more support than this. Psychosocial intervention programs that include counselling by trained helpers can be beneficial for those refugees whose usual traditional and natural structures are not enough. In setting up a psycho-social program for a population of refugees, our first response is not to set up a counselling structure. First, it’s an assessment of problems, needs and resources. Then, based on the assessment a multilayered response is created for the multiple layers of problems. It begins with ensuring that all people receive relief in ways that promote their psychosocial well-being and ensures that family and community supports are enabled and encouraged to assist their members. Intervention programs, like counselling, are set up to help with psychosocial problems only when the natural systems are not enough. Even then, the intervention programs are designed to build the capacities of the families and communities to care for themselves. If there is a “counselling program” then local people are trained to run it so that it goes along with the culture and traditional values. The medical mental health component for serious mental disorders is essential but it is the smallest part of the response and preferable is based within the public health system.
