Cover Story - Pain Beyond Physical Wounds

With her granddaughter, a woman is having an MSF support session in a migrant shelter in Mexico. © Marta Soszynska/MSF
Worldwide, one in four people suffer from some kind of mental health disorders during their lifetime, however, 60percent of sufferers do not seek help. These figures increase dramatically when factors such as violence, persecution, the need to flee, or disasters are added.
There is a growing recognition globally on the need to provide mental healthcare. But reaching out to people caught in humanitarian crises is much needed. They are especially prone to depression, anxiety, and other mental health disorders. 
In 1998, MSF formally recognized the importance of providing mental healthcare as part of its emergency work. In the past decade, MSF conducted 1,786,406 individual mental health consultations and 285,118 group sessions. Last year, mental healthcare formed a key component of medical services in over 70% of the countries where we worked. 
Trapped in Conflict with Loneliness and Trauma
Mariia, 79, eastern Ukraine. © Kenny Karpov
“October 2015 was the worst month of my life. There were shootings and explosions all around my house. I remember hiding in my back room and getting horrible news. My neighbour ran in, and told me that my son was badly injured by shrapnel. He died in front of me. I was helpless. After my son’s death, my nerves were destroyed. I was shaking a lot. I couldn't eat. He was my helper, my everything.
My sister has asked me to leave Opytne. But it's my home. My son and husband are buried here. I cannot leave them. I’d rather die here than anywhere else. I've been visiting the MSF clinic for treatment with my nerves and high blood pressure. Before my son’s death, I didn't have such problems.”
Four years of conflict have severely altered the lives of people living in eastern Ukraine. Over a million people have been forced from their homes. Partially-abandoned villages are mostly home to elderly people living in isolation, who are struggling with rising prices yet insufficient pensions. Many are in desperate need of medical care to treat chronic diseases, and psychological support to help them cope with stress and loneliness. MSF runs mobile clinics in 28 locations across the Donetsk region, providing primary healthcare and mental health consultations. The team also supply medical facilities with drugs and equipment and conducts mental health support training for teachers and government healthcare professionals still living or working in the conflict zone. 
An 86-year-old woman looks at the hole where a shell hit her apartment in Donetsk, Ukraine. © Manu Brabo
Bitter Memories of Dangerous Journeys
In northern Ethiopia, the MSF mental health team in Hitsats camp meets weekly to discuss the main challenges and issues that they encounter. © Gabriele François Casini/MSF
Ephraim was only 14 when he first attempted to leave Eritrea. Like many others, he tried to reach Libya, but was caught, jailed and beaten along the way. He was sent back to Eritrea, where he was thrown in a military prison. Since then, he started to have severe stress and repeated nightmares. He stopped eating and isolated himself. Finally, the military called his mother.
Three years later, and after several other attempts, Ephraim managed to reach Ethiopia. He brought few physical possessions, but came burdened with anxiety and post-traumatic stress disorder resulting from torture, violence and abuse he had faced in the past years. 
Ephraim, 17, Eritrean refugee in Ethiopia. © Gabriele François Casini/MSF
“When my mother realised that I wasn’t doing well, she took me to the holy water for seven days. That’s our traditional remedy for mental health conditions. My symptoms persisted. The only thing I could think about was how to escape again. After two weeks, I tried to cross into Ethiopia again…Up until recently I still had nightmares. I couldn’t sleep and was feeling angry all the time.”
In northern Ethiopia, MSF mental health centre in Hitsats refugee camp offers counselling, inpatient and outpatient psychiatric care, and a wide range of therapeutic activities including therapeutic discussions and psycho-education. Around 40% of the camp population are children. Half of them have travelled alone or have been separated from their families. 
Shattered Life
Tatiana*, Central African Republic © Olivia Watson/MSF 
*Name changed to protect identity
“My husband was killed by armed men, and I was taken prisoner. In their camp, the men raped me. I was held there for several days, and lost one of my children. Finally, I managed to send the other child out of the camp, and I fled too…After talking to the counsellor for some time, I feel a bit better. But it’s not easy, not easy at all.”
Tatiana’s voice was almost inaudible as she recalled what happened to her. Her story is not an isolated one. Sexual violence has been widely used as a weapon of war in Central African Republic, and civilians currently face another escalation of violence. Across the country, MSF treated 1,914 victims of sexual violence in the first six months of 2018. In Bangui, the country’s capital, MSF opened a specialised clinic to care for people being sexually assaulted. Since its opening in December 2017, nearly 800 patients have been treated. The majority are women, and a quarter are under the age of 18. Not only the medical team helps prevent sexually transmitted diseases and treat injuries or gynecological complications, but the psychologist also tries to reduce the impact of the aggression and alleviate the mental symptoms.  
At MSF’s clinic for sexual violence survivors in Bangui, Central African Republic, a quarter of patients are under the age of 18. This children’s play room allows younger children the space and time to feel safe in the clinic. © Olivia Watson/MSF
Guleed Dualeh: ‘Mental healthcare is about trust’
Guleed Dualeh, MSF psychologist. Photo source: Guleed Dualeh
Physical wounds can be mended, yet mental injuries are hard to heal. That takes a long time, and requires people to be willing to share their stories. To Guleed Dualeh, MSF psychologist, mental health support is about communication, and communication cannot be established without trust.
Like other MSF psychologists, psychiatrists and counsellors, Guleed had to overcome different barriers and limitations for providing care. In 2015, he was on mission in Myanmar, providing psychological first aid for the displaced Rohingya with the support of a translator. ‘A visibly distressed woman explained her situation and experiences to our translator, talking for about 15 minutes in local language. In the end, the translator just gave me a one-sentence summary: “She is not doing well”. Obviously, the woman had said much more than that. But it appeared that our translator wasn’t comfortable to repeat her account. It’s worth highlighting that there could be a risk of vicarious trauma for the translator when interpreting another person’s story, as that might recall his own experience being from the place.’
Building trust with patients is another challenge. “They wouldn’t necessarily trust, and open up to a new face every month. That’s why MSF tries to send psychologists to the field for at least 6 months, unless they are there to conduct a needs assessment in which direct contact with patients is not required; we would also deploy psychologists to go on shorter missions toprovide psychological first aid in emergency situations.” Consistency and time is key in modelling the psychologist from a stranger to a trustworthy person. Another solution is building the capacity of staff recruited in the community. They are usually counsellors or lay counsellors. Sharing the same language, cultural background and experiences with the patients, they get connected with them easier. In addition, the psychologist has to ensure that all counsellors are listened to and no one is left behind. 
Staff’s mental health is a critical element for MSF’s human resources management. Often away from home for long periods of time, working under enormous pressure and required to process the traumatic events, field workers need professional support and headspace. Guleed, who worked in three MSF missions, has been the Psychosocial Focal Point for MSF – Hong Kong since last year. He conducts systematic psychological briefing and debriefing for field workers before and after their assignment, and is working toward a network of regional psychologists for providing proximate support for field workers recruited from 13 territories in Asia.