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Lachal C. Setting up a mental health care mission Why ? When ? How ? Bobigny : Association Internationale d'EthnoPsychanalyse ; 2005. Available from : http://www.clinique-transculturelle.org/AIEPpsy_lachal_
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Setting up a mental health care mission 
Why ? When ? How ? 

Christian LACHAL

From Palestine to Sierra Leone and back again : problems in setting up mental health programmes

Since 1993, I have been actively involved in setting up a number of mental health programmes, mainly in Palestine, but also in Sierra Leone and Peru. My first assignment, in 1993/1994 - knowing nothing about M.S.F. - was an exploratory mission to the occupied Palestinian Territories in the West Bank and Gaza where I was to establish the criteria necessary for starting a mental health mission. Strangely enough, these criteria were all assembled in the situation in Palestine at that time. The needs and the means were there - people traumatised by the seven years of the first Intifada, especially the children, adolescents, and families who had taken an active part in the conflict ; the director of a Palestinian N.G.O. who had come to Paris requesting M.S.F.’s help ; a network of local professionals to work with and train in the field who had a concept of psychology and psychopathology which was reasonably similar to our own ; M.S.F.’s desire to be involved just as the Washington peace accords were attracting hundreds of N.G.O.’s into Palestine. It was an ambitious project – setting up a consultation centre for children and their families who were suffering from secondary problems having lived through the first Intifada ; the staff were mixed, each expatriate team member having his or her professional Palestinian counterpart. We set up the project with a Palestinian N.G.O., who was to take it over after the initial phase. The place : Jenin, a town which had been very militant during the first Intifada, and therefore had many victims,far beyond the reach of all the humanitarian organisations then flocking to Gaza. The time : shortly afterwards. The Washington accords had just been signed, security wasn’t a serious problem, and it was time to care for the « hidden wounds » of this sad period. And yet, whilst all the elements necessary for a successful programme seemed to be in place, the project suffered a series of setbacks and was closed down at the end of eighteen months having failed to reach its objectives. It is not possible to analyse the reasons for this semi-failure here ; it can be said, however, that when setting up a mental health programme, the evolution of the social, cultural, and political contexts is critical – whether in giving the project its positive and dynamic impetus, or, on the contrary, in impeding its development and effectiveness.

On the other hand, some highly successful programmes have been set up in haste and amidst all sorts of difficulties and uncertainty. This was the case, for example, with a programme aimed helping released detainees from Israeli prisons after the Oslo accords. We had to work with a Palestinian team who, for the most part, were ex-prisoners themselves, and who they themselves had problems – however it was forbidden to mention them. This demonstrates the difference between the collective and the individual aspects of trauma : one can talk about the collective experience of the suffering endured in prison, of torture, or of deprivation, but it is assumed that the individual has managed to overcome his own personal experiences, and won’t complain on his own behalf. This is particularly true for people who take on responsibilities within their own social group - in this case, the staff of the Palestinian Ministry for Social Affairs - but it’s a point we must bear in mind for all our staff. We had to be mindful of the tensions between different political groups - exacerbated by their experiences in prison - the issue of traitors and collaborators, the fine dividing line between the political (witnessing) and the psychological (care) aspects : everything, in fact, seemed to indicate that the project could never work. The person who took it on was in charge of programmes for former detainees ; he had been in prison himself, and thought it quite natural to have psychologists working alongside his teams. We were very unsure whether to proceed with the project or not, and our psychologist was instructed to carry out a lengthy (two month) evaluation. The Palestinian team - made up of militants and combatants who were fundamentally opposed to the project - fought against him every step of the way, but the programme was eventually made possible on the basis of two simple premises : the first was to look upon the Palestinian team’s opposition as a perfectly reasonable stand to take in order to deal with the after-effects of their prison life, to give this a positive value, and to bear it in mind when setting up our action plan. The second was that in order to work together, we needed female staff who had not been involved in the conflict, and who were not burdened by difficult past experiences. Despite everything that separated them, an expatriate psychologist and a young Palestinian social worker, self-taught in psychology, managed to implement a successful programme even with these « hard cases ». Our initial objective might be to try and minimise the differences between carers/clients or between expatriates and the populations they are trying to help ; on the contrary, it is sometimes easier to work together by playing on, or utilising these differences (in this case, the differences in the sensitivities and social status of men and women). I will come back to this point about differences between people later on, but want to illustrate it by giving two examples : in one case, the mission went ahead, but in another, the project was abandoned.
 
In Sierra Leone in January 2000, the situation was barely stable in Freetown, and war was continuing throughout the rest of the country. Hundreds of people, victims of amputation by machete, were being treated by the M.S.F. surgical team at the Connaught Hospital in Freetown before being reunited with their families in Murray Town Camp, also known as the « Amputees’ Camp ». Handicap International had been providing equipment and therapy, including a psychological component, since the opening of the camp. An exploratory mission (of too short a duration) had noted numerous cases of children and adults suffering from psychological trauma. Whether amputees or not, they had much in common ; they had all been through a particularly horrifying war, had become refugees in their own country, had lost everything, and were unable to return to their villages. We now understand to what extent these losses made them dependent on N.G.O.’s and other international aid agencies for refugee or displaced populations – and to what extent they were therefore vulnerable to the dubious conduct of certain members of these organisations. What is certain is that in Murray Town Camp at that moment, there was the place, the time, the needs, and the means. And yet, the mental health care plan for the camp’s victims never saw the light of day. One of the reasons for this was the resumption of the war and the threat to Freetown, which made it difficult to send more staff - especially psychologists - into the field. It is common for psychologists and psychiatrists to be less « resilient » than others in a war environment, and it is therefore preferable to delay their intervention until the post-war phase. Once the war is over, the situation becomes calmer and there is time to think without being caught up in the action. It is at this point that the individual, introspective self can take control again, having previously abandoned this part of him simply in order to survive. Another point – often raised in our discussions about the Sierra Leone project – was the doubt about running a successful mental health programme with a population whose traditions and way of thinking were so far removed from our own.

The programme, which opened in October of the same year in Gaza, contradicts the previous statement about the fragility of psychologists and their way of working. The programme had been drawn up following much discussion, some of it bitter. It was implemented during a war amongst populations confined to geographical pockets as defined by the military segmentation of the Gaza Strip. At the end of the rapid exploratory mission in October 2000 to clarify the situation in the « cauldron » that was then Gaza, one question was uppermost in our minds : « What can we possibly do ? » We were appalled by the things we had seen, and staggered by the enormity of the task ahead with a population of nearly one and a half million people. How should we go about it ? Who should we treat ? Or not treat ? The first point was to differentiate between the collective trauma - common to the entire population - on the one hand, and on the other, the individual needs in terms of psychological care. The second point was the need to concentrate on certain zones which were more exposed to danger and destruction (residential areas, olive plantations, roads etc), where there was confrontation with the army, or places where children and adolescents were particularly vulnerable - for example, they inevitably took risks when constantly faced with soldiers, tanks, gunfire, and threats. Thirdly, the Palestinian mental healthcare network was semi-paralysed or confining its activity to Gaza City where certain populations were deemed important for political reasons e.g. families of the martyred or wounded, and so we needed to provide substitute care. This did not exclude collaborating closely with the people already in place ; on the contrary, we invested heavily and immediately in the team - the translators, the drivers, and all the staff without whom this kind of work (which involved immediate access to the Gaza community and its families) would have been impossible. The fourth point was for us to move about, to go out to the people who were unable to come to us : the project was designed to be mobile. In fact, the people themselves knew very well what help they needed, whether this be medical or psychological care, or both. The fifth point was to quickly assemble a mixed team of doctor and psychologist. Strangely enough, the objections to the project had less to do with problems of security - a crucial issue, nevertheless - or the criteria we had identified, than with a clinical discussion about post-traumatic stress disorder (P.T.S.D.) : we knew how to treat P.T.S.D., we knew about the problems which would surface some time after the trauma, but we had no idea about treatment during conflict or war, at the very moment these traumas occur one after another.

There are many other examples to illustrate the following point : that at the present time, it is difficult to be absolutely definitive about the criteria for setting up a mental health mission. I believe that such criteria need to be drawn up separately for each individual project after an initial evaluation, which takes into account not only our previous experience, but also the discussions, which, as we have seen, can sometimes raise unexpected issues. These are all issues that psychologists and psychiatrists simply must address. The arguments against setting up a project are just as important as those for ; they allow for careful elaboration, even though psychologists and psychiatrists see them as presumptions. I shall now discuss some of these, and then attempt to extract some generally agreed principles for setting up mental health care missions.

Some presumptions in humanitarian psychiatry
Humanitarian psychiatry is a superfluous luxury when there are so many un-met medical needs

I shall quote Dominique Martin (1995 : 18) who made the point that « Humanitarian aid is not only concerned with physiological needs ; it must take into account the complexity of Man, his very being. Restoring his capacity to choose freely and to influence the world is as essential as providing him with food, shelter and medical care ». We can add to this a certain number of additional arguments. The first is quantitative : the high incidence of psychological problems in the context of war is now a well-established fact. This means that we are not talking about exceptional cases or people who are especially fragile or sensitive, but about a health issue of considerable importance. The most vulnerable (infants, children, adolescents, or women), those who present with illness or deficiency are particularly affected. There is consensus about the almost obvious conclusion to be drawn from this : that psychological intervention should be introduced after certain urgent and primary measures have been implemented. It is a question of intervention strategy (Moro 1995), but the rule « psychological after somatic aid » is not an absolute one. We have seen (as in Gaza) that the medical and the somatic can function concurrently. We can also mention the mother-infant programme in Hebron, which targets the dyads and the families where a child’s life is in danger due to malnutrition – often severe – associated with the mother’s psychological problems. Karine Grouiller (1) carried out a study of this programme, and demonstrated the importance of psychological care first in certain cases : of the 382 children studied over the four and a half year programme, 57% presented with malnutrition as the result of an isolated psychological cause. With an average treatment time of 5 months, 65% of the children had improved (i.e. had not died from malnutrition) and had started to put on weight ; 5% had died.

Treating people with psychological problems resulting from war makes no sense, since such people are not « sick » in the true sense of the word

We know that this problem exists and how to tackle it (as in Gaza) by identifying families, groups or geographical zones which are particularly at risk. We can also ask ourselves in a refugee camp in Sierra Leone : Do we treat everyone ? How are we going to decide who does/doesn’t need our help ? Amongst all these people who have been through the same traumatic experiences, how do we identify « the traumatised » ? To clarify these issues, it is useful to distinguish several levels of psychological suffering. It is true that many people experience traumatic events that do not trigger any significant problems ; others, on the contrary, develop problems that can be very incapacitating. It is difficult to define each individual’s resilience, his vulnerability, or his breaking point. Once this stage has been reached, the person will present with genuine psychological problems, even though he was previously « normal » i.e. before the traumatic events/the war. Our first priority is therefore to distinguish very carefully between the traumatic experience (the horror of the events), the reactions which should be considered as normal adaptations to such events, and those which should be described as pathological.

When you work with small groups of people who have been through the same experiences together, you note that they can clearly identify those amongst them who are suffering beyond the limits that the group recognises as « normal ». It is therefore extremely important to take note of what they take to be an indication of suffering or failure to adjust. An example from Kenema Refugee Camp, in Sierra Leone : if an adolescent refuses to go and fetch wood, or to take part in other communal duties, there is obviously something very wrong - it is a cry for help which has real meaning for the entire community. Another example in another context : a little boy of five or six, in Tabbah, southern Gaza. We were in a house that had been half-destroyed by Israeli gunfire ; the families living there were all together in a room on the ground floor. Shots flew past the house as we talked, and the acrid smell of tear-gas was everywhere. This is to say that everybody in that room – including ourselves – was frightened ; we were all experiencing the same traumatic event. And yet, the mothers identified this one particular child as suffering psychologically, as being traumatised. When we carry out this process of identification and differentiation, it is important not to label people as « sick » ; at the same time we must not forget the - sometimes very serious – impact such events can have. In collective terms, we have learned that the most vulnerable individuals within a population (infants, adolescents, women), and in a wider context, vulnerable populations, help us to identify needs and determine our intervention methods more accurately.

Treating people when war or conflict is ongoing makes even less sense, since they will be repeatedly re-traumatised

This brings us back to the issue raised earlier i.e. the relevance of intervention at the time traumatic events occur, and the specificity of our approach in such situations when in theory, we only know how to provide care afterwards. There are, however, two clinical points to distinguish and consider : the issues of recurrent and accumulated traumas and when to intervene. It is a fact that we always work with people who have accumulated traumatic events and very rarely with those who have just had a single experience. Bereavement, loss of all kinds, inhuman acts, fear, lack of schooling, violence (both inflicted, as well as received), deprivation : the number of blows to a person’s integrity is often far greater than the traumatic event itself. It is not necessarily the same people who are traumatised each time, but it is often the case that an individual person experiences a series of traumas – a series of losses, several attacks, a number of constraints etc. We are always faced with complex individual or family backgrounds. Traumatic events are an integral part of these backgrounds – they are not something external, a « foreign body » that can be extracted like a bullet from a wound. They are interwoven with memories, with the collective account of events, and with the way in which a particular community construes and portrays what is (and what is not) traumatic. The second issue (direct intervention during ongoing conflict versus delayed « dressing of psychological wounds ») has made us revise our working practices in line with military psychiatry, especially for the mobile project in Gaza. If one follows military principles of care e.g. those of Salmon (1917), it is better to intervene immediately, in situ, and providing basic care, which focuses on symptoms. The moment of intervention (the « when ») determines the problems needing treatment and the way in which such care will be managed (the « how »). In Gaza, we managed the situation in this way by a series of 5 or 6 brief home-visits.

One of the distinctive aspects of working in the middle of a war is to see at close hand what people are going through, to be plunged into « the eye of the storm » with them : the storm destroys everything around you, but at the centre of it, there is a strange sense of stability - what might be called the « neo-culture » of war and survival… Being there at that moment obviously reduces the distance that always exists between caregivers and receivers to a minimum, but it is impossible to say whether this emergency care has a preventative value in terms of reducing the impact of future trauma. In Gaza, in Hebron, in places where the conflict is ongoing, we are more concerned with psychological intensive care (helping the most damaged to get over a critical phase) than with curative or preventative issues. Deciding on the right time to start a mental health mission does not just depend on clinical judgement. The political philosophy of the N.G.O., its standpoint in a particular country, security - these are all factors to be taken into consideration. A conflict is always perceived and interpreted in different ways, and psychological input has to fit into the sometimes contradictory ebb and flow of such perceptions.

The cultural differences between care givers and receivers are such that mental health care is impossible

One might think from the above that this is a problem specific to mental health, and therefore not relevant to surgeons or nutritionists ; this is absolutely not the case. The last M.S.F. symposium on problems of nutrition in humanitarian settings (2) clearly demonstrated the importance of cultural factors in malnutrition and its management. In terms of mental health, we often work in contexts where the local traditional methods can be very different - even contradictory - to our own. This is true of humanitarian medicine in general, as noted in Ronny Brahman’s recent work (2000). He reports that in certain famine situations, the elderly (as the guarantors of social cohesion) claim priority for food, whereas our moral hierarchy would feed the most vulnerable and the children first. And so, we have to find a solution, a strategy that takes account of the different viewpoints humanitarian organisations are constantly faced with. This example illustrates the following fact : that concepts of suffering and psychological disorder, the somatic and the social, differ greatly from one culture to another, as do concepts about treatment methods. We are thus obliged to adapt, modify - even sometimes abandon - our Western principles, but it does not mean that we should assume we are unable to intervene.
This brings me back to the fundamental principles on which transcultural work in the field of psychology and psychiatry is based : in particular, the idea of a psychological universality which has a unique and different version for each culture/family/individual, with a concurrent contextual influence which reaches the core of the family and intimacy. It is evident that some mental processes and certain types of suffering are universal, but these can be altered by the interpretation of a specific culture. On the other hand, the context of life is by no means insignificant in relation to psychological functioning, in fact it influences and shapes its every aspect : emotional, cognitive, relational, fantastical, and – in a very significant way, when dealing with children and adolescents – developmental. (Moro 1998). These two laws apply as much to caregivers as to care-receivers. Expatriates have to immerse themselves in a culture that is different to their own, and they undergo changes that may sometimes be profound, whilst those on the receiving end are immersed in a context of war or violence, which can have profound effects on their way of thinking, feeling, dreaming, or expressing themselves. This is perfectly illustrated by Charlotte Beradt’s study (2002) of dreams in the Third Reich, which has much to teach us about the way in which a context of terror can influence the most intimate aspects of mental function. War fabricates a particular cultural context. The violence of some human behaviour and certain kinds of suffering can drastically change the very bases of our way of thinking. For example, it is difficult to reason about human nature in a positive, adaptive way when you are confronted with what B. Doray (2000) rightly describes as « inhumanity ». In the face of this constantly growing « inhuman knowledge » - from the scientific and administrative aspect of the final solution to the making of child-soldiers - we have to equip ourselves with as much information and « know-how » as possible if we are to reach our objectives. It would be unthinkable to view the events a person has witnessed solely from his own perspective : this is an important point to emphasise, because some people will do just that for reasons of efficiency ; for example, in an attempt to rid people as quickly as possible of the pathological reactions which make up the symptoms of post-traumatic stress disorder by using standard, universally applicable methods. This approach does not take into account the complexity of certain situations, and more precisely, the transcultural context of war or disaster.

And so : do we start a programme in Sierra Leone or not ? Is it harder to look at the way child-soldiers are trained, sometimes using very contemporary conditioning methods, or the way they are treated during the purification ceremonies which represent their traditional form of therapy ? In a camp in Kenema, a young expatriate psychologist - not trained in transcultural psychiatry, but sufficiently self-confident and at ease not to impose - works with children using a variety of methods which represent not only her own ideas and those of her local assistants, but also those of the children themselves, influenced in turn by their own culture (3). In another camp in Kenema, an American N.G.O. organises its programme in situ, combining problem-solving techniques (4) with cathartic techniques that closely resemble local cleansing ceremonies (5). In terms of training, there are workshops on trauma, but also on traditional perceptions of death, the dead, children, marriage, rape, etc. I use this example because it seems to me that helping the people of Sierra Leone to set up mental health care mechanisms appropriate to their needs is not the most problematic issue. In fact, the hardest thing to consider in the midst of the ongoing conflict is this : how can a mental health programme operate in a country where executioners – some of whom even belong to the government now – are able to circulate freely without being brought to justice ? How can we start a mental health programme in a country that doesn’t even respect human rights ? Is there a precedent ?

Mental health care is time-consuming, costly in terms of human resources, and directed at so few people that it is not worth the trouble

There is no doubt that psychological temporality is different to factual temporality. This is why at first, it was thought that mental health care projects could not coincide with emergency situations involving care for millions of people at the same time ; mental health care on that scale does not, in fact, exist anywhere. This has prompted some N.G.O.’s to use a psychosocial or community approach that aims to mobilise and train mental health workers in basic skills so that they can treat or help a greater number of people. As already mentioned, this is also what drives us to look for more rapid treatment methods : we target the trauma, we use very quick techniques (de-briefing), and those workers who seem best able to implement such methods are targeted for accelerated training schemes. Unfortunately, the effectiveness of these techniques is far from established ; they may even, at times, prove to be more harmful than therapeutic (Summerfield 1995). In addition, to isolate the trauma and to focus solely on the P.T.S.D. is to ignore a large number of contextual problems and reactions which - although linked to war or displacement - cannot strictly be considered as part of the post-traumatic state (e.g. depressive, anxious or psychotic states, bereavement, psychosomatic problems etc. or, in children, difficulties with sleeping, learning, feeding, enuresis etc.).

M.S.F., along with other French N.G.O.’s, has opted for a dual strategy : to measure the complexity of situations and at the same time, to set limits. Sierra Leone, for example, has no mental health care system to speak of - virtually no psychologists, and one psychiatrist to cover the whole country. There is no way we can pretend we are going to resolve problems on a nationwide scale. And so, our decision has been to select a refugee camp for « returnees » (6) where we have set up training mental health auxiliaries who will benefit from complementary training provided by other N.G.O.’s. In Gaza, we go out to the families who live in precise zones of the Gaza Strip. Such decisions and ways of working do not mean that we are unaware of the country as a whole ; they are objectives, which, although sometimes challenging, are attainable within our limitations.
The therapies we offer are not particularly time-consuming (indeed in some cases, they can be of very short duration) but they must be adapted - on a number of levels - to the complexity of a situation : the social group, the family, the mother and child, the individual. The worst possible thing is to do nothing because we can’t provide care for everyone ; on the other hand, we must not delude ourselves by thinking we can deal with the traumas of an entire population.
We could analyse many other common presumptions. For example : Psychologists and psychiatrists differ so widely in their conception of psychological problems and their treatment methods that it is impossible to draw up guidelines or standardised techniques. Programmes revolve around the notion of P.T.S.D. and those people who have reactional, rather than chronic, pathologies - independent of war or disaster. Since the programmes do not focus on the mentally ill, they exclude the very people most in need of help. On this last point, I would simply say that although the mentally ill do not fall into the target population for most mental health programmes, they tend to be included anyway, since they figure among the most vulnerable and fragile. In the mother-baby project in Hebron, for example, our initial objectives did not include the care of children with developmental pathologies (genetic, perinatal, etc). A significant number of these children were nonetheless included in the programme because they were malnourished ; their mothers were unable to feed them because of complex problems and the vicious circle of a personal pathology influenced by a number of other factors : psychological, familial, economic, etc.

Why ? When ? How ?

Having made the above points, I think it is clear that at the present time, we do not have the operational criteria that allow us to respond to these issues in any definitive way. It is worth remembering that mental health care programmes have been in place for barely fifteen years since the Armenian project after the earthquake in Gumry in 1988 (Moro 1995). I will nonetheless attempt to make some basic suggestions as a prelude to establishing recommendations for the implementation and follow-up of mental health missions. In the interest of clarity, I have detailed five parameters for each of the three questions in the title : Why ? When ? How ? (See figure 1).

Why ? A question of ethics

Our primary motivation in setting up a programme is a moral one : people have experienced suffering, loss, and the constraints imposed upon them by war or disaster. Their own resources are insufficient to cope with this, and they need help. This is a simple premise, but one which needs to take into account both the type of suffering and its causes.
 
1/ Fight « inhumanity » with humanitarianism

Numerous psychological strategies are used during conflict. War does not only use weapons to kill and injure, it perfects methods - whether instinctively, or in a studied way - to kill and maim in a psychological sense, and also to produce efficient combatants. In this way, war has just as much effect upon the individual as on the population as a whole. We cannot look at the question of psychological trauma without considering the way in which the trauma has been inflicted by the combatant on his adversary – what we might call the making of a trauma. Without going into complex psychological explanations, I will simply refer to the philosopher Hannah Arendt (1990) who described the way in which a person’s humanity can be destroyed by having « experienced desolation » - having reached this point, he is then equipped to commit the worst kind of atrocities himself.

2/ Populations « in danger », exposed, at risk

Rather than talking in a military way about target populations, I prefer the term « populations in danger », the title employed by M.S.F. in a number of its annual reports (7). When a population is in distress due to war or other arbitrary causes, humanitarian aid takes place within a precise political, sociological, and historical environment. It is not simply a question of an external intervention in a crisis or an emergency ; it can take place in the post-war period or when war is brewing and - together with climatic and economic factors - plunges a population into famine and distress. For practical reasons, humanitarian psychiatry has come to define sub-groups according to the violence to which they have been subjected : so, for example, we have « rape victim » programmes, « street-children » programmes, etc. We need to be aware that such categorisation can have perverse effects – in particular, in stigmatising people who have a far more complex identity than the psychosocial label allocated to them. We might do better by identifying areas and contexts which make people especially vulnerable in social and psychological terms : perhaps by using an estimate of psycho-social distress such as « Population in danger : level 1, 2, 3, » etc.

3/ Identifying needs

In order to explain and give meaning to this « level of distress », an exploratory mission should identify and evaluate needs in a medical and empirical way. It is often the case during this type of mission that our contact with the population, the people who are active within their community, and the associative network, is far more important than that involving protocol or administrative agencies - where these exist or have managed to survive. It is important, too, to remember the astonishing capacity with which people can always identify their own psychological suffering - as long as they can do so « apart », and not just during collective discussion. This of course implies that we must go out and meet them!

4/ Specific damage to social structure

In some situations of anomy, where social and cultural disruption is extreme, when we talk - rightly or wrongly - about « chaos », we can be certain that people will be severely affected. When social structure is threatened or deteriorates, this affects all the inter-individual social ties simultaneously. Violence penetrates into the very centre of family life, and touches even the most intimate relationships : mother-child interaction in the Hebron infant malnutrition project, or the numerous child-soldiers who are subsequently unable to integrate back in to their families, or the break-ups in cross-cultural families during the wars in ex-Yugoslavia, for example. The ties between individuals are of the same « nature » as « intra-psychological » ties, i.e. they give coherence to our thought and our actions. The need to help people in situations where social structure has been seriously damaged seems obvious.

5/ Humanitarian space / an enclave of humanity

A mental health mission can be set up once an N.G.O. (such as M.S.F.) has already created the necessary climate of confidence with the local population. We have recently started to use the term « humanitarian space » which in my view, implies that our first task is to establish an area that provides a minimum of security or safety. A mental health project is never (and never should be) seen as separable from this aid, or presence, or care. Psychologists and psychiatrists have an affiliative relationship with their N.G.O. ; it is their cultural niche. They do not work for themselves, even though their own individuality is strongly involved. They can help to change this cultural niche into an enclave of humanity by using their own personal techniques - for example going beyond the horror a person has seen, and moving on from witnessing to psychological aid.

When ? A question of strategy

The right time to implement a mental health project depends on logistics which are difficult to explain. They are complicated, and do not just depend on technical details (care needs, problems in accessing aid, lack of professional skills etc.) These aspects are of course taken into consideration and discussed, but other factors tend to get in the way - the N.G.O.’s political philosophy, the current situation in a given country, the gathering of witness reports etc. We are ready to implement a programme when :

1/ We decide to associate the moral and political representation of the facts with a psychological and cultural one. This is the transition from empathy to trauma : aid workers obviously feel empathy for the distressed populations with whom they work. Their first reaction is to say « This is awful - we must bring in some psychologists to help these poor people. » We have to get past this initial emotional reaction, which is of short duration, and move on to a clinical approach, which may or may not focus on concepts of traumatism and the post-traumatic state. In the same way, the legal aspect - more and more a part of humanitarian work - will reveal situations where people are suffering as a direct result of attacks on their integrity (communal, familial, physical, psychological). Here, we move from humanitarian rights to considering the « harm done » when individuals and their culture are the objects of violence : how this modifies such things as child-care, growing up, adolescence, starting a family, etc. Everyday human behaviour can be greatly impaired when basic rights are denied or ridiculed. Here again, we have to make the transition from rights to intervention, from witnessing to care.

2/ The situation is urgent. This may be due to a medical emergency (the infants in Hebron, for example, could have died from malnutrition without psychological intervention), or an emergency in terms of the current situation (as in Gaza, where the living conditions imposed by war necessitated both medical and psychological input).
 
3/ A population requests help. Either directly (as in the first M.S.F. mission to Palestine), or indirectly e.g. when the local medical teams recognise a need for psychological input. Medical and logistical work implies close contact with a population ; the teams are therefore ideally placed to identify psychological impairments resulting from war or disaster, and can then request additional psychological/psychiatric help (as in the medical programme in the refugee camps in Kenema, Sierra Leone).

4/ It is logistically feasible. A minimum level of security is essential - both for expatriates and the local population (8). It is obviously important that the N.G.O. is in place in the field beforehand – for example, it would have been unthinkable to implement a medico-psychological programme in Gaza at the end of 2000 had M.S.F. not been involved in Palestine since 1993.

5/ There are no time constraints. Reservations about the length of a project are often raised when discussing mental health programmes. In fact, it is possible to provide treatment over relatively short periods of time i.e. which last no longer than programmes of a purely medical nature. We must, however, bear in mind the following two points : firstly, that post-traumatic disorders do not just stop when the war stops - here again, note the vital distinction between events, traumatic experiences, and problems which are secondary to trauma. The post-war phase is one that is busy with the re-construction process and full of hope – but it is also one that is marked by all sorts of psychological and psychosocial problems. One has to take treatment times into consideration, but above all, we must not forget that certain kinds of post-traumatic problems can be of long duration. In addition, it is always necessary to consider the perspective of the mental health programme in the context of the war and the post-war phase, and to consider individual experiences alongside the collective experience. Mental health care does not take place in the abstract ; it is strongly influenced by contextual evolution. The personal development of refugees in the Sierra Leone camps, for example, will be greatly affected by being able (or unable) to return to their own villages. On the other hand, this in no way implies that all their psychological problems will be resolved once they return to their homes. We must not confuse the communal collective background with each individual’s personal background, but rather be aware of the way in which the two interact with each other.

How ? The issue of « resilient » programmes

One of our most crucial problems in designing mental health programmes is to make them « resilient », as we say today i.e. solid or strong enough to absorb the shocks caused by the events and difficult contexts that surround them. When I say programmes, I am in fact referring more to the people who implement them, because such projects depend above all upon the personalities of the people in the field, whether expatriate or local. So, how can we make our mental health programmes sufficiently « resilient » ?
We have to draw up plans that take local resources into account on a number of levels. These resources allow a population to maintain a certain level of organisation in the midst of all the upheaval and disarray that war creates – for example, by producing a collective account which lends meaning to traumatic events, even though this account may be a blend of reality and imagination which represents real and imagined fears. To illustrate this point, we can look at the way in which the Palestinians perceived the gas used by the Israeli Army - as being poisonous and deadly. In fact, it was neither, although it was true that it presented a real threat to young children, asthmatics, and people with respiratory insufficiency. Traditional local resources (including familial and group solidarity) which help people cope with psychological, somatic, and physical suffering exist in all societies ; we also need to explore the pre-existing care networks and those which will be able to endure and continue afterwards. Human resources must be evaluated with particular care : professionals, people who can participate in the process, those who have ideas, and can sometimes take on the responsibility for the programme. They may be doctors (highly competent, but caught up in the maelstrom of war) or carers with varying levels of training, but they can also be social workers, teachers, volunteers, etc. The associative network has an important role to play : we depend on this to help run programmes, but also with a view to taking them over or continuing them should the N.G.O. decide to withdraw. The issue of taking over projects is always an important part of the logistics of humanitarian aid i.e. ensuring that the people we help do not become dependent on us, and can eventually utilise our input to help themselves. On the other hand, we must not worry if they take over and run programmes in a way that is different to ours : there have been a number of programmes which have developed along very different lines from those we had at first imagined e.g. in the West Bank, the project in Jenin consisted of a consultation centre providing psychological support for children and families, which was due to be taken over by a trained local team and the N.G.O. which had requested our help. In fact, by the end of the first year, the team had broken up, and its members dispersed throughout the new Palestinian administration to become school psychologists, project managers etc. As they were still able to utilise their skills in their new surroundings, the project was closed down.
N.G.O. resources also need to be considered. There is much to be said on this subject, but I would just emphasise two points. The methods employed by psychologists and psychiatrists involve a great deal of personal investment : to counteract this, they have to be able to stand back from their work and put it into perspective, which is why we try to ensure we set up supervision systems. Advice and support from consultants is also valuable. Planning is an essential phase in mental health programmes, and needs to be worked on in more detail.

Collaboration with cultural « mediators » is of the utmost importance e.g. the translators (who have a fundamental role since they take part in consultations and translate not only the language, but also the culture), the drivers, the logistics experts, the different individuals and members of the community who help N.G.O.’s in one way or another. This makes me think of the programmes in Palestine, where Israeli psychologists supervised both our expatriate and our Palestinian psychologists, thereby allowing the two sides to communicate with each other in the context of conflict. These mediators open doors for us, they guide us and protect us, and clarify things we might otherwise not understand : they act as our « scouts ».
An intervention must integrate the five « classical » objectives of a mental health programme, which are as follows : to console - working with a group or a community, and implying presence, dialogue, empathy, and sometimes prevention ; to provide care - using techniques appropriate to the context ; to provide training – using tutoring and other more « academic » methods ; to witness – mindful of the fact that psychologists and psychiatrists have a particular role here, and must clearly differentiate between this and their clinical work ; and lastly, to evaluate.
The clinical work must of course, form the core of the programme. There are a number of specificities in clinical psychology and psychiatry : although mental health professionals are part of the medical team, they have their own distinct techniques and pace of work, and it requires efforts on both sides to produce a real medico-psychological collaboration. In my opinion, treatment and concurrent staff training programmes in the field cannot be mixed up with social support. An example : street-children need both medical and social aid, but we also need to offer them a specific psychological or psychiatric approach. This is not an educational support, or just a friendly helping hand, but rather a specific approach which targets the secondary psychological problems caused by their individual backgrounds.

I would like to end by making one last point, followed by a quotation. The important point is this : there is a great deal of reflection and re-thinking going on in the field of humanitarian psychiatry today. M.S.F. is very involved in this process with its think tanks, its education, training, symposia and publications. My quotation comes from that most « resilient » of figures, Bertolt Brecht’s Mother Courage. She has lost Schweitzerkas, one of her sons, her second son Eilif has gone missing, and her daughter Kattrin - who is mute - has just been attacked whilst purchasing items for her mother, who makes her living from the war. At this moment, a Regimental Commander’s funeral cortège passes by :

« Chaplain : Look – they’re burying the great Commander. It’s an historic moment.
 Mother Courage : They punched my daughter in the eye - that’s what I call an historic moment! She’s already half done for, the poor thing - adores children but she’ll never find a husband. She’s only dumb because of the war after a soldier stuffed something into her mouth when she was young. I’ll never see Schweizerkas again, and God only knows where Eilif is..
A curse on the war! »

BIBLIOGRAPHY

Arendt A. La nature du totalitarisme. Paris : Payot ; 1990.

Beradt C. Rêver sous le IIIe Reich. Paris : Payot/Rivages ; 2002.

Brauman R. (Ed.) Utopies sanitaires. Paris : Le Pommier/Fayard/Médecins Sans Frontières ; 2000.

Doray B. L’Inhumanitaire ou le cannibalisme guerrier à l’ère néolibérale. Paris : La Dispute/ Snédit ; 2000.

Green E, Honwana A. Indigenous healing of war-affected children in Africa. IK-Notes 1999 ; (10) : 1-4.

Labaume C. Paroles d'ex-détenus palestiniens. L'autre, Cliniques, Cultures et Sociétés 2000 ; 1(3) « Dire sa souffrance » : 531-3

Martin D. Psychiatrie et catastrophes : le point de vue d’un humanitaire. In : Moro MR, Lebovici S. (Eds) Psychiatrie humanitaire en ex-Yougoslavie et en Arménie. Face au traumatisme. Paris : P.U.F. ; 1995. p. 17-20.

Moro MR. Tremblement de terre en Arménie : le psychiatre et le réanimateur. In : Moro MR, Lebovici S. (Eds) Psychiatrie humanitaire en ex-Yougoslavie et en Arménie. Face au traumatisme. Paris : P.U.F. ; 1995. p. 129-51.

Salmon TW. War neuroses (shell-shock), Lectures, illustrated with motion picture films, prepared by Direction of the Surgeon General for use in the Medical Officers Training Camps, N.Y. National Comm. Mental Hygiene. Mil Surg 1917 ; (41) : 674-93.

Summerfield DA. Debriefing after psychological trauma. Inappropriate exporting of western culture may cause additional harm. BMJ 1995 ; 311(7003) : 509.

Figure 1 : Why, when, and how to set up a mental health programme ?

RESUME

Mettre en place une mission de soins psychologiques : Pourquoi ? Quand ? Comment ?
Un peu partout dans le monde, de nombreux programmes de soins psychologiques sont ouverts, parfois en complément des soins du corps, parfois en première intention. Il s’agit de soigner les « blessures invisibles » dans les contextes de guerre, les camps de réfugiés ou les situations de violences chroniques. En prenant son autonomie au sein de la médecine humanitaire, la psychiatrie humanitaire se doit de préciser et d’évaluer ses critères d’intervention et les résultats de ses actions. Cependant, nous ne disposons pas, aujourd’hui, de critères opérationnels qui nous permettraient de dire avec précision et à chaque fois pourquoi, quand et comment ouvrir une mission de soins psychologiques. Il est donc nécessaire de mieux expliquer notre façon de concevoir la psychiatrie humanitaire. Cela ne suffit pas à définir des critères opérationnels. Il faut tenir compte de l’évolution toute récente de la psychiatrie humanitaire en France, depuis à peine quinze ans. Je propose quelques idées de base, début de « guide-line » pour l’ouverture des missions de soins psychologiques.
Mots-clés : Psychiatrie humanitaire, Critères d’ouverture de programme, Soins psychiques, Traumatisme psychique.

ABSTRACT

Setting up a mental health care mission : Why ? When ? How ?
Mental health care programmes are set up all over the world, either together with medical aid programmes, or on their own. The aim is to treat « invisible wounds » in the context of war, in refugee camps, or in situations of chronic violence. As an independent part of humanitarian medicine, humanitarian psychiatry must define and assess its intervention criteria and the results of its actions. However, we do yet not have operational criteria which allow us to define why, when and how to set up a mental health care mission. We therefore need to better explain our perception of humanitarian psychiatry. This is not, however, enough to define operational criteria. We have to take into account the recent evolution of humanitarian psychiatry in France over the last fifteen years. Here, I suggest some basic ideas, an outline for guidelines on setting up mental health care missions.
Key words : Humanitarian psychiatry, Criteria to set up a programme, Psychological care, Psychological trauma.

RESUMEN

Puesta en obra de una misión de atención sicológica : ¿ porque ? ¿ como ? ¿ cuando ?
Numerosos programas de atención sicológica son abiertos un poco en todas partes del mundo, a veces en complemento a la atención del cuerpo, a veces en primera intención. Se trata de cuidar las « heridas invisibles » en los contextos de guerra, los campos de refugiados o las situaciones de violencias crónicas. Al adquirir su autonomía en el seno de la medicina humanitaria, la siquiatría humanitaria se debe de precisar y de evaluar sus criterios de intervención y los resultados de sus acciones. Al día de hoy, sin embargo, no disponemos de criterios operacionales que nos permitan de decir precisamente y a cada vez porqué, cuando y como abrir una misión de atención sicológica. Es necesario entonces de explicar mejor nuestra manera de concebir la siquiatría humanitaria. Lo que no basta para definir criterios operacionales. Hay que tener en cuenta la muy reciente evolución de la siquiatría humanitaria en Francia, desde hace solo quince años. PropNGOo aquí algumas ideas de base, esbozo de una « línea-guía » para la apertura de misiones de atención sicológica.
Palabras claves : Siquiatría humanitaria, Criterios de apertura de programas, Atención sicológica, Traumatismo síquico.