This entry has been hard to write. The fact is that while trauma is used as a medical term, it is deeply embedded in our social history, meaning that it has political, legal, economic, and moral components.This is fascinating stuff, and I can think of no better starting point than the concept of trauma to dive into how psychiatry itself, and the therapies it deploys, are themselves products of a rich social history.But after many starts, I’ve realized that this blog entry ain’t the place!  I want to write on what we say and do in Farchana or Arkoum when sitting with a person on a mat under a tree.The theory informs our practice greatly, but this is another discussion.  For people who want to track this down, I highly recommend reading the following two books:

• “Inventing posttraumatic stress disorder: a harmony of illusions” – Allan Young (1995)
• “Understanding Trauma” – edited by Kirmayer, Lemelson and Barad (2007)

What I want to address here is, in a sense, the first and last question that we need to ask ourselves as confidants, counsellors, caring friends and neighbours: what can we do to help someone who we think has been traumatized?  In the Farchana mental health services, we see many people who have lived through horrific events, and we talk a lot about what we can, should, and should not do to help them.About a week ago, we sat down for a few hours and explored this, and here I’ve amalgamated their words and experiences with some of the psychiatric lingo that is commonly used.

In other words, what can a counselor say to Ahmed when told of Amane’s story?  He is waiting for a response that is useful.

Assume Resiliency: First, assume that the vast majority of people are going to get better without professional intervention. The counsellors in Farchana know this intuitively, whereas back home early intervention is more the norm.  I think an evolutionary perspective helps explain this phenomenon of resiliency: for literally millions of years, humans have lead lives that have been characterized as solitary, poor, nasty, brutish, and short.  Deaths were by infection rather than chronic diseases, mortality rates (especially in infancy and childhood) were high, and violence and food shortages were common. Whether you now wear a business suit, an animal skin or a tutu, you’ve got a brain that was baked in the Paleolithic period.  Even in the more recent ten-ish millennia since the invention of agriculture, these conditions have mostly persisted. Adaptation to stress was a necessary part of survival and often a source of individual strength and community bonding.Humans are survivors, and assuming that someone who suffers is a helpless victim is rude, crude, and wrong.

Listen and Follow: Listen to what a person says and feels and simply hear them out, using empathy and curiosity as guides. The counselors tell me that often they’ll spend up to three one-hour sessions just listening before they finally start asking anything specific. Statements like “How’re you doing now?” “Do you want to talk about it?” “Then what Happened?” and “Holy shit that sounds terrifying! What was it like?” strike me as good starters.  Sure, they’re campy, and even run the risk of being cliché, but that’s no big deal.  The most common form of an epiphany is when you get the deeper meaning of an otherwise throwaway statement.  Note that open questions are much more useful than directives; an open question would be like the ones above, whereas a “closed” question has a yes-or-no form, such as “were you sad when that happened?”

In most sources on this subject, there is both an encouragement to get someone to “tell their trauma story” in full detail and emotional tenor, and to let people know that they are having a “normal response to an abnormal event.”To me, it seems better to say something like “some people benefit from talking about it” rather than prescribing this path.  Likewise, I find the phrase “a normal response” troublesome.  In some senses, “normal” implies “expected,” and we don’t want to give anyone the impression that feeling better quickly, or not having any “traumatic reaction” is unexpected or in any way “abnormal.”  I think it is better to say something like “you’re not going crazy, what you are going through is an understandable response to what you’ve been through, and the vast majority of people feel much better in a few weeks to months.”  This is both true and encourages health rather than focuses on the sick role.  Of note, it is much more therapeutic for a person, if they are to tell their story, to have a high level of emotion as they go through it.You can say the words till the cows come home, but if there’s no emotion, there’s less benefit.

The final question at the end of our session is, of course, “would it be helpful for you to come back and see us again.”  If no, a smile, a well-wishing word, and a statement that our services are always available, are phrases commonly used by the staff.

Red Flags: A red flag is something that makes you think that professional help is likely necessary.  Things like suicidality, violence or escalating aggression, panic attacks, refusing to eat or drink, extended bizarre behaviour and confusion are the most common.  The formal intervention is to keep a person and those around them safe while in this state.  As well, if someone is not getting better and several weeks to a month has gone by, this may be time to ask for help, too.  Of course, some people may want to see a therapist without these red flags being present, and that’s fine, too. I just wouldn’t push for that.  Lots of studies have shown that one-off “debriefing” sessions after a difficult event can make things worse.

Encourage family and community support:  Healing is like learning to trust again… and trust means being comfortable with letting another take care of you. Family, close friends are the obvious choices, but it could be your ultimate Frisbee team-mate, rabbi, hiking buddy or flower vendor.  We’re all in this together.

Encourage meaningful activities: This could mean doing laundry or helping someone build a latrine or tukul. It could mean cleaning up after a meal or taking your half-hour walk everyday.  Something with a start, a finish, and a feeling of satisfaction that comes with the accomplishment.  As soon as someone is capable, going to school, a volunteer position, a job—whatever—is good.  Join the knitting bee, have tea with the regular group, or get back to the chess club… just get back into the world as fast as possible.  One study found that people who looked after children got better faster. Makes sense to me!

 

As I write this, the wind is whipping outside.  I have no clue what time it is because my Tukul is near lightfast.  But somehow, even though light doesn’t make it through—I write this with my head-lamp on—dust has no problem getting itself everywhere.  The is no such thing as a surface in Chad without a fine patina of dull-brown sand.  I’ve noticed that I stop closing my teeth together because I feel the “crunch” of small grains of dust.  And when I chew bread at mealtimes it’s more of a mashing without clamping down for the same reason.  My hands are cold.  It heats up to 40 degrees in the daytime, and at night it’s around 15.  To me, this is utterly bizarre.  You layer up in the morning and peel ‘em off as the day progresses.  I just returned from watching the sun-rise.  Nature here is so stark it that it has a sci-fi quality.  This glowing red orb peeking it’s head above the distant steppe.  Soon we’ll drive west for an hour or so, checking in with various people along the way to assess security concerns.

Yesterday the mobile clinic showed up Hillé-Déyé, a town in the region of Alasha, and an IDP camp by the same name of about 2000 Chadians.  There was a strange shine to everything, as there’s a silver iridescent mineral in the rock in this region.  So the thin layer sparkled in the sun, almost as if a magic spell had been cast betraying the gravity of the situation.  It is a silver lining around a storm-cloud.

When our two land-cruisers drove in, all the kids came swarming around, smiling and yelling “ok!” or “ça va?!”  It was a sea of bright faces set against the sheen of glitter on tattered clothing, like an 80s party in a Disneyland dystopia.  It was quite infectious, and you just can’t help smiling along.

Our mobile clinic, which has been functional for about a year, finds its “clinic” in the shade of a tree.  But today it was too windy, so we fixed up the thatched-mat sheeting on the side of one of the two school-room structures and stayed there for three hours.  Within ten minutes, the collapsible tables were up, and everyone was in place.  Registration and triage outside, peri-natal care in the back corner, a nurse in another, the pharmacy in a third corner.

Jochen, the German nurse, handles vaccinations for a while, and is consulted on difficult cases, and Sam, a Chadian nurse’s assistant by trade, works with maternity and nutrition.  The place is swarming, and despite the initial appearance of chaos, it runs smoothly and quickly.  I came to Chad to see how medicine functions in such places, and how mental health finds its niche in the fray.  How mental health could find its place in the fray, more specifically.  My first impression was  wonderment at how two fully packed land-cruisers and about ten people can do so much work in such a short period of time.  One young girl had a nasty infection on her foot that was not healing.  Jochen decided to explore it surgically and he pulled out what looked like a piece of animal bone.  It seems so minor, but without this minor surgical intervention, a child may very well have died of sepsis (when a trenchant infection goes throughout the body in the bloodstream).

The mobile clinic works with Chadian Internally Displaced Persons (IDPs).  Most come from the “border” with Sudan, which is nothing of the sort.  It’s a patch of land with no political or other fence-type markings, of course, and people identify themselves by language, ethnicity, and means of subsistence.

Noura is the mental health counselor with the mobile clinic.  She lives in Arkoum, one of the three mobile clinic sites, where the team goes for several days of the week.  Noura is one of those people who can talk to anyone and get them to tell their story, and has many of those “non-specific factors” that make therapists effective: she cares, listens well, engenders trust, and exudes a sense of calm.  You can’t fake such things as “genuineness” and “presence.”   Noura and I walk through the camp to see her patients, most of which have been referred from the Community Health Workers (CHWs).  I watch how women and men come up to her and say hello, and ask to sit down with us to speak their minds.  Several times, someone tells us of a person who cries at night and may benefit from our stopping by.  And we do.

Here are a few stories that we heard. (Note that for confidentiality, names have been changed, as well as some details of the case that do not alter the significance.)

One man, whom I’ll call Ibrahim, was found sitting with a group of male friends.  He’s in his early thirties and is relatively new to the camp.  He jumped up when he saw Noura, excused himself, and found a straw sitting-mat to put on the floor around the corner, under a thorny tree.  He had intensely dark eyes, and looked at me while he told me his story.  It seemed to matter little that Noura was translating from Arabic, I could see his eyes and hands and hear the tremble in his voice.  Several months ago he was relatively happy, living on “the frontière,” lands between Chad and Sudan.  He had two wives, five children, and many family members around.  He told of how “the Janjaweed came and took everything.” The Janjaweed are commonly held to be the Arab, Sudanese-government backed militia. When they came, and he hid under his bed while they killed his brothers, one wife, and all of his children.  Ibrahim hid all night in terror, no knowing who was alive or dead, but he heard voices and dared not come out.  It has been three months since he has been in the camp, and at night he sees “men on horses” in his dreams, and he awakes screaming. When asked about his thoughts during the day, he pauses, and tells me that they took 100 cows, 10 camels, 3 horses, and a mill to grind grains.  Ibrahim is starting to feel a bit better, although he still feels distant from his wife.  He misses his family and his stability, but despite the continued threat of violence in the village (which is NOT imaginary), he is making ties with the community, has found occasional work making bricks, and is thinking of starting a small herd of sheep. He plans to work his way up to cattle again.  I ask Ibrahim if he finds his sessions with Noura helpful, and why.  It’s a fair question, and Noura understands that this is not a knock at her.  He says that Noura is the only person to whom he talks openly about his losses, and that he feels much better after he talks to her.  He tells me that it was Noura who suggested he start raising animals again, and although he thought she was crazy at the time, it sounds like a good idea now. He does not smile at all, but Noura does occasionally when they speak.

Fatna is an eight your old girl who cries at night, and neighbours come and sit with her.  We are directed to her by a woman who is one of Noura’s patients, and eventually come across the right straw door and someone answers our call, bidding us enter. We sit on the straw mat, the women kindly offering me the prized corner in the shade of midday heat. Fatna is quiet and says nothing, even when asked simple questions like her name and age.  Her mother instinctively answers, and I’m told that she has not spoken for ten days. I write this a week later, and it remains a heartbreaking story. In silence, with her short and tightly braided hair and curious eyes, one shoulder of her dress ripped and falling askew, she evoked an almost overwhelming empathic response.  This is her story.  Two years ago, she was out “on the frontière” with her father when the “Janjaweed” came and hit him with their “horse-sticks” until he fell. They continued to beat him, and Fatna’s mother described how her daughter spoke of blood coming out of his head. She ran into the “brousse” (a word that means something like country-side, bush, outback, or the steppes).  She does not remember how long she was alone, but said that it could have been a few days. Eventually Fatna returned to her house and, as it was a market day, nobody was home. Her mother returned home and found her in a corner, crying. It was weeks before she told anyone her story, but by then they had heard news of the body of her father that had been found by other villagers. The family packed up and left quickly, and Fatna was doing pretty well in the IDP camp, her mother tells me.  She had friends, was enjoying school, and laughed and played with the other children. Then, about ten days before I met her, she was again out in the brousse, and men on horses came and harassed her and her friends. The other kids ran, but she froze, and was the only child still there. They said angry things, but she did not run. She was hit on the back and chest with the “horse-sticks,” and was left there by the men, in that catatonic state of fearful rigidity.  Apart from slight bruising, she had no physical injuries. But since then, she has not gone to school nor has she played with friends.  A few hours after sunset, she cries out inconsolably because she sees men coming “with horses and knives.” Nightmares wake her up and the women in her block come and sit with her. They will continue doing this, and we encourage her to go back to school as soon as possible, for half-days at first.  And she listens as we encourage her to have her friends visit, even if it takes her a while to speak to them.  Fatna’s mother listens to our words about “stress reactions,” and asks when the mobile clinic will be back to visit again.