The psychological element of the project is delivered as a package. All components must be in place, in the form of direct services or of a referral, to ensure a comprehensive programme. The package includes the following components:
• Psychiatric support: in acute emergencies expatriate and national medical staff gives psychiatric support within the project. If possible clients are referred to existing medical or psychiatric services. When referral is not possible (for instance if services are sub-standard or non-existent) the psychiatric support is continued through medical doctors in the MSF (primary) healthcare service.
• Counselling: counselling is offered as emotional support to individuals and small groups. The counselling does not aim primarily to heal or to cure people of their psychosocial problems. In situations of acute or chronic humanitarian crisis and exposure to traumatic events, healing or curing is an unrealistic objective. The role of the counsellor is to support and improve people’s coping mechanisms. Supportive counselling provides emotional support and practical advice. It helps people to increase their self-control through education and improvement of their social skills, and to boost their resilience by mobilising their own physical, mental or social support mechanisms. The counselling interventions are based on cognitive behaviour techniques and brief therapy principles that are translated to the existing cultural environment.
In order to cope with traumatic experiences, the survivor needs to be able to give them meaning. In many non-Western societies, meaning is given through the spiritual world. Spirituality is an important coping mechanism, but the areas of moral and spiritual health are difficult for Western NGOs and psychosocial counsellors to address. Psychosocial projects can include spiritual leaders as advisors or as referral options. Rituals and ceremonies can be stimulated. Nevertheless, it should be borne in mind that humanitarian aid workers are also bound by their own ethical principles and quality standards.
• Training: training of national staff introduces or increases existing skills, knowledge, and competencies. National health staff are trained to identify psychological and psychiatric problems as well as, for instance, in communication skills to offer basic support to their patients. National counsellors are trained to give more intense individual support to survivors of violence and to work in the community. A specific training method has been developed for the training of national counsellors108 (see Chapter K: Training).
• Advocacy: Proximity to clients is essential for showing empathy, solidarity and compassion. The changing environment requires continual monitoring of needs.
Where needs are highlighted through interactions with the clients, these should be discussed with the project coordinator or Medical Coordinator.
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The ‘socio-’ component
The social component of a project addresses psychosocial problems on a group level. A package of activities is proposed to stimulate the re-integration of traumatised people and to facilitate coping among large groups. The ‘social’ package includes the following components:
• Practical support: traumatised people need practical and physical support to enhance their recovery environment. Medical services, water and sanitation assistance or food support are just some examples. The needs are often overwhelming, so to ensure appropriate referrals of those in need of practical support, expatriates, national counsellors and community workers need to know what is available in the community. A ‘social map’ must be researched or drawn up and made available. To provide adequate support and to foster self-help mechanisms, a full understanding of social and culturally appropriate methods is vital. Since not all support can be expected from the community, close cooperation among NGOs must also be stimulated.
• Community education: large-scale education about prevailing psychosocial problems in the community is necessary to gain maximum advantage from self-help techniques. Education self-helps to break down taboos about mental health and psychosocial problems and increases awareness about counselling services.
• Community mobilisation: communities’ social fabric is often affected by mass violence. This results in a reduction of people’s protective mechanisms. After mass violence, the regeneration and revitalisation of community structures often needs outside support. Cultural leaders such as chiefs, religious leaders, and elders must be encouraged to re-assume their roles. Grassroot initiatives need assistance and stimulation since they often provide vital practical support. Local cultural groups such as theatre groups or folk/singing companies can do a great deal to improve spirits and community cohesion.
• Community activities: The atmosphere in camps for refugees and internally displaced people is often far from uplifting. Community activities can be used to improve the general atmosphere, to stimulate community action on general issues such as hygiene promotion, or to re-start community cultural customs such as dancing or storytelling. These activities improve the sense of belonging. Extensive networking with community leaders and (folk) artists are required to achieve this.
Integration and comprehensive medical services
The nature of mental health and psychosocial care requires a multi-disciplinary approach.
The evident relationship between traumatic exposure and poor health emphasises the fact that intense collaboration between primary and specialty medical care109 is essential to improve early identification and treatment. Mental health interventions must be managed as integrated elements of health interventions as much as possible.
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Fig. 2: Intervention model for psychosocial projects to address the psychological consequences of violence through individual and community interventions.
Physical, mental, social, spiritual, moral problems
Social package
- PRACTICAL SUPPORT - COMMUNITY EDUCATION - COMMUNITY MOBILISATION - Key people - Grass root organisation - COMMUNITY ACTIVITIES
- Distraction - Networking
Psychological package
- PSYCHIATRIC SUPPORT - COUNSELLING SUPPORT - Education - Emotional support - (social) Skill training - Advice
- TRAINING OTHER HEAL TH STAFF
Integration
Not coped Avoidance
Vulnerability (pre/during/post and vent-related)
Intrusion Resilience
physical, mental. social, spiritual, moral health
Coping process Potentional
Traumatic event(s)
PSYCHOSOCIAL AND MENTAL HEALTH INTERVENTIONS IN AREAS OF MASS VIOLENCE 35