29. Reflections on Chad and Sudan – The Rule of Law


I get parking tickets now and again.  It happens.  Here’s how the conversation went semi-recently:

I got a ticket

Oh, that sucks. 

Kind of.

You’re just saying that, of course you’re pissed.

Nope, not pissed at all.  In fact, I get a slight rush of happiness when I get a ticket. 

uh… wha? 

Growing up in Thornhill, Ontario was a standard, Canadian, secular-cloistered environment.   When I started driving, at around 16/17, I would occasionally get parking tickets and feel hard-done-by.  When I was driving and heard sirens behind me, my stomach would drop.  Thankfully I never got a speeding ticket, but still, I recall the quasi-instinctive fear of the law. This feeling more or less diminished throughout my life, but the residues remained; tickets are a bad thing.

In Chad, there is no rule of law that is worth mentioning.   There was a local administrator in Farchana, and often I was trotted along to negotiations now and again as it was viewed as a sign of respect to bring medical team members to meetings.   The fellow could be abrasive and accusatory, and other times could be downright pleasant.  He could do whatever he wanted.  He had a type of power that is unknown in other parts of the world.  He could set the truth conditions for the world around him, if only a small chunk of the world.  That which he said was wrong was wrong, and his word was generally unquestionable.  Negotiations were delicate, to say the least.

This fellow casually stated one afternoon, during a meeting, that he allowed MSF to maintain its medical mission with relative safety.  Nobody doubted this.

During a car-jacking, as I mentioned in a previous post, an ex-pat humanitarian aid worker from France was shot in the head.  His death may not have been entirely accidental, and the repercussions for the local community was effectively absent.  This was a sanctioned occurrence, it appeared.

Harsh, arbitrary and radically discretionary punishments, meted out by the local warlord was the way of life.  Human rights were negligible.  Women’s rights were almost non-existent.  This was the furthest thing from a meritocracy I had ever seen, and it made me sick to my stomach.  It struck me for the first time how crucial the rule of law is to undergirding civilization.  (I wondered what other fundamentals were necessary and sufficient, such as payment of living wages, adoption of the scientific method, etc.)


Back to modern day Toronto.  The fact that one can leave their car for an extra 20 minutes for which payment was not made, and there is a surveillance system that is generally fair, universal, enforceable and contestable is a great achievement.  A seemingly small thing, but flowing from an absolutely necessary, and in a way, a wonderful system.  Even if I’m out $30 for tarrying a bit.

28. Darfur, Sudan – The Magic Quarter

Fast-forward to 2013.  I’ve been working as a forensic psychiatrist at CAMH in Toronto for about 4 years, and it’s been a fascinating apprenticeship and practice at the intersection of psychiatry and the law.  A multidisciplinary team assesses, treats and risk-manages, aiding those with mental illness in transitioning back to the community.   But this post is not about the job.  It’s more about reflecting back on the missions, some years past.

First, a bit about Sudan.   About three months after returning from Chad, in mid-2008, I was asked to join a mission in Nyala, Sudan.  Kalma Camp was, at the time, the largest refugee camp in Darfur, and some said that it was the largest in the world, with about 150,000 internally displaced persons (IDPs).  It was a troubled time, of course, but another emergency had reared its head.  The sitting president was being investigated for charges of war crimes of the worst kind, up to and including genocide.  He had been tolerating humanitarian aid in the country because to not do so looked pretty bad.  Well, in the wake of the impending indictments, he decided that such bad press was the least of his problems, and he was moving to kick all humanitarian aid projects out of the country, and mental health was going to go first.  The mental health staff speak to people, and in gathering stories, so the presidency was concerned, might collect information that would be injurious to his human rights record.

I was only to interact with MSF staff, and have no direct patient contact.  No journalism of any kind.  No cameras.  No notes were to leave the country.  Any transgression would result in being jailed.  This was made very clear to me, and I signed several Arabic language documents (which my translator struggled to explain).  My translator impressed upon me that even suspicion of wrong-doing is enough to be jailed.  And Sudanese jails are the stuff of nightmares.  These people were not fucking around.  Blogging was, of course, verboten.

So MSF needed a psychiatrist to go in ASAP and work with three local doctors on matters of assessing, diagnosing, treating and managing persons with schizophrenia.  There was a small and closing window, so to save time, MSF sent me to Nairobi, Kenya to try and get a Sudanese visa more quickly.  It took some doing, but a week later I was on my way to Khartoum.

The worldwide prevalence of schizophrenia, fairly consistent across all ethnic and social strata, is about 1% of the population.  So in a camp the size of Kalma, one would estimate, all things being equal, that there would be about 1500 persons with this endogenous psychotic disorder.  But that’s a big assumption, the equality part.  The political situation was, to put it mildly, chaotic.  Surviving a dangerous situation, especially a protracted one, takes great organization, stamina and resolve.   Vulnerable populations such as the elderly, children, and persons with physical or mental deficits, are less likely to stay alive without support structures in place, and these very structures were being torn apart by the violence.  It was impossible to state how many persons with schizophrenia were in the camp, but the project had about 200 persons for whom they were providing regular care.

If you want to do emergency psychiatric work, and get the most immediate, profound and potentially enduring benefit for the population, there are many strategies. One of them that should be included is to find the schizophrenic population and, in consultation with their family or other supports, offer low doses of antipsychotic medication.

Steven Cohen CAMH | haldol

Medication is the single best intervention for schizophrenia, and while it does not cure, it controls many symptoms quite well in a large percentage of the treated.   Haldol, an older and well-established medication, was available in large supply, and was available on the open market (through pharmacies; no prescriptions are necessary in Sudan).  Of course, MSF had its own supply chain, and the medications were of the same standard as those provided to anyone in Canada.  But while emergency and relief humanitarian aid does the best it can, and for a whole host of reasons, a person with schizophrenia or their family may need to access antipsychotic medications in the future and not have access to an established clinic, and thus it is very helpful to have a medication that has a local supply chain.

Haldol (or haloperidol) is still used regularly by Canadian psychiatrists, although often for more acute psychosis accompanied by agitation and aggression.  It is in the Canadian guidelines for medical management of schizophrenia.  The well-worn prescribing mantra of “start low and go slow” fit the situation.  Most of the persons with whom mental health staff have contact in Canada are well known to the system, and have been tried on one or more antipsychotic agent, and usually in high dose and even in combination with another medication.  In Kalma Camp, by contrast, almost every person treated was neuroleptic-naïve, which meant that they had never taken a medication of this drug-class.  Haldol came in 5mg increments, and to allow for some sort of standardization, we cut them into quarters (1.25mg per piece) and started there.  Avoiding side-effects while getting the best effect with the lowest dose was the goal, as it always is.  And it turned out that 1.25mg, twice a day, was the optimal strategy.

One day a fellow with schizophrenia was brought in by his family for follow-up care.   He had been started on Haldol before I arrived in the camp, and I was seeing him at what might have been his “best baseline” or mental status at his best treatment level.  I’ll call him Abdul, although for the life of me I can’t recall his name…  I kept no notes, something that was prudent, but most regrettable nonetheless.  Abdul was in his early-20s.  His family provided most of the history: Abdul started exhibiting psychotic symptoms (the harbingers of what would become fully blown schizophrenia) in his mid-late teens.

While he was once gregarious, athletic, and sociable, he became more reserved, isolated, and unable or unwilling to engage in basic behaviours such as maintaining hygiene, social protocols and schooling.  Unfortunately, he also developed strong paranoia, and believed that his brother was trying to do him harm.  About two years prior to when I met Abdul, he became aggressive, and killed his brother.  His family recognized that he was ill, and was not to be punished, but they had to contain the risk, and chained him to a log.  Abdul could move slowly from one place to another, and was cared for by his family as best they could.  The family found antipsychotic medication in the marketplace (the pharmacy medications, likely of purer provenance, were too expensive), which had some beneficial effect, but not consistently so.  The family heard of the MSF project, and travelled between camps in order to find treatment for Abdul.  He had been treated with MSF-provided antipsychotic medication for about a year prior to my having seen him.  Abdul was pleasant, conversant and fairly engaging, albeit somewhat emotionally detached, and he mainly answered questions that were posed to him rather than speaking spontaneously.

He was well-dressed, living with his family, and was taking part in the family business.  He was betrothed to be married.  Abdul recalled little of the incident leading to the death of his brother, and his family jumped in and explained that this was not the “real Abdul… it was the sickness in him.”   Abdul recalled being chained to a log, and while it was deeply unpleasant for him, he recognized on some level that his family was acting in his best interests, and he did not appear to harbour any resentment for it.  He indicated that he needed the medication to stay well, and that the “magic quarter” had saved his life.  I agreed that his family and the magic quarter (of Haldol) had saved his life.  The status of the MSF project was in jeopardy, and the Abdul and his family were understandably quite worried about what would happen if the free medicine became unavailable.  They were provided with a solid supply of the medication.  To this day, I wonder how Abdul is doing now.

The structure of the day involved waking up early in Nyala, eating a perfunctory breakfast, and hopping on the “landy” (Land Rover) that took 45 minutes to get to Kalma Camp.  The bench seats in the back were simple wood planks, and six or eight people would cram in.  The terrain was rough.  I had tweaked my back (degenerative discs are not kind to the aging), and could feel the bumps.  We’d arrive at camp, and I’d head off to meet with the three local doctors.  We spoke in English, but also had a translator for some of the trickier concepts.  We saw patients with their families all day, and made time for a lecture over the lunch-hour.  One after the next, each doctor would take turns assessing, presenting the case to the team, proposing a treatment strategy, and then discussion and implementation.  This happened as many as 20 times a day.  Rough and ready guidelines flowed from these discussions, and they were translated in Arabic.  MSF encouraged the guidelines to be distributed widely, and many photocopies were left with the Sudanese doctors.

By the end of my two months, the three doctors were not only managing this population well, but were holding their own lectures for other staff, and training what would be their support staff for the continued clinic.  It was a resounding success.  I was elated, proud to be a small part of MSF and the mission.  And it felt like something new, something that I resolved not to forget, as it is so easy to.  I was not a simple cog in the machine out there, but a part of something larger than myself in which I had a crucial role.  I was part of something that would not have taken place had all the elements not been in place.  There was a type of satisfaction in this work that does not often come from other types of work.  It was brief, meaningful, and nourishing for that core of the self for which we have so many names but nothing concrete.

Steven Cohen CAMH | Us.Stock



20. Logistics, nimbly

Steven Cohen Psychiatrist store.room

Much of the work that we do out here is focused on the final act: the prenatal exam, the psychotherapy session, the assessment, diagnosis and treatment of disease, supplements and monitoring for the malnourished. In a very real sense, the good people in Berlin and Amsterdam support the administrative Country Management Team (here in Abéché), who in turn support the logistics arms of the many projects all along along the eastern border of this godforsaken land. And they, in turn, support the medical people. Us nurses, doctors and midwives are left with the task of patient care, pure and simple. Food is on the table, pantries full, land-cruisers to transport, medical centers running triage, pharmacies stocked, electricity flowing, water delivered.

Steven Cohen Psychiatrist plumpy.mozzy Steven Cohen Psychiatrist U.med.stock Steven Cohen Psychiatrist bechir_stock

Organizing anything in Chad is no mean feat. This is a place where no opportunity for misunderstanding goes unexercised. Where negotiations often start with a stalemate or a threat and progress from there. Where everybody is needling and clawing for money and kickbacks. Where the security situation hangs over you like a thundercloud in the distance; you never know when it’s going to break.

I wrote a couple of weeks ago about the murder of Pascal Marlinge, the Head of Mission for Save the Children (StC). That day, all NGOs stopped providing non-essential services and retreated to the safety of their respective compounds. StC, understandably, never resumed. Within a week it was unofficially known that they would, again understandably, suspend all their activities and most likely leave the country. This left Breidjing Camp, with 30,000 refugees and 12,000 local IDP Chadians with no organization providing medical care. A vacuum.

Steven Cohen CAMH Breidjing Steven Cohen CAMH brick_pits Steven Cohen CAMH morning.convoy Steven Cohen CAMH base.A,pic CdS.hamlet1

This is the story of how MSF took over services and within two weeks, were up-and-running at full capacity.

People. Jochen, our mobile clinic nurse with many years of field experience, stepped up to the Project Coordinator position (PC). With a solid handle on both the medical and logistics side of things, he hit the ground running and hasn’t stopped since. Jean-Marc, the technical logistician also stopped on a dime and headed that way, as did almost all the national staff on the mobile clinic team. Ivan, our PC here in Farchana (but he basically likes to do everything, and would if given half the chance) got to planning. Since ground transport has been declared unsafe, Breidjing would need an airstrip. Ivan called up Karline (our Head of Mission in Abéché) and asked for authorization to build one. On the phone, at that moment, she said yes, and within two days 159 local workers had been hired and were on the job. Within six days the first flight landed and took off, notably bringing Ivan back to Farchana.

Steven Cohen Psychiatrist Toronto fox.convoy Steven Cohen Psychiatrist Toronto chariots Steven Cohen Psychiatrist Toronto plane.plumpy

A full complement of staff were hired and given contracts. Stock rooms were inventoried and new medications and supplies ordered. Endless meetings with local authorities, and long conversations into the night about what to to the next day. It was, as Ivan calls it, “E-team mode,” which stands for Emergency-team. If there are locks on doors and you can’t find the keys, you cut the locks. You don’t think of overtime costs for national staff, you just work till the day ends (although notably none of the staff even asked for extra pay). Administrative authorization lagged behind implementation. Often. The lines of communication were open throughout, but decisions were made on the ground.

Notably absent from this story is the call for funding. In most organizations, it would take months of proposals and oversight to fund a project that effectively costs about a million Euros a year to run. It’s an onerous, paper-heavy task, leading to what could best be described as administrative fatigue. MSF, however, is independently funded. This means that beforehand they do not need to knock on government doors, UNHCR doors, or whomever, to ask for the means to provide health care. There is minimal lag. The airstrip, which incidentally had been “in the planning” for three years, and was built by Ivan et al. in five days, cost about 2000 euros. This is the cost of doing business out here. Health care for a population of 42,000 people for a whole year. Fantastically reasonable. In my view, administrative fatigue is rather low in this organization. Every cent is accounted for, of course, but money in MSF, at least from my vantage point, is not a “power-grab,” it’s just grease. My guess is that everyone over the age of six knows how rare this is. It likely would not escape the purview of an astute six-year-old, either.

Steven Cohen Psychiatrist Toronto HAH.lunch CAMH Steven Cohen dramatroupe3 CAMH Steven Cohen dinner CAMH Steven Cohen sm-team Steven Cohen Forensic Psychiatrist  jidomobile Steven Cohen Forensic Psychiatrist  Giuliana_Paule

I include the numbers because they interest me, and I figure others may want to know as well what things cost. Money is important.

This is a proud moment. (I was on vacation, so I feel justified in beaming without seeming the least bit self-congratulatory.) On the day that Pascal was killed, Ivan, Jochen and Edith (our logistics administrator) sat under the mango tree and spoke about what it meant for them to work out here. It hit them hard. But the conversation went from personal reflection to planning. What if StC left Chad? What would need to be done to keep primary health care services in Breidjing. It had to be MSF. Literally, nobody else could do it, given the administrative fatigue of other operations. They sat down with paper and pencil the next day and started mapping it out: a proposal to make it happen ASAP, for about two to three months, until a long-term solution could be found.

Group identification is a funny thing. I hear people all the time saying of their favourite football, hockey or basketball team that succeeds: “we won!” This is absurd. In the words of Chris Rock, a comedian, “no, six black guys, who would hate you if they knew you, won.” This is not absurd. But it does highlight the extent to which people ignore every register of class division and common sense to feel associated with something winsome. All of a sudden my friend who works in a bank, from a sheltered, privileged and rather sanitized petit-bourgeois childhood is character-identifying with Shaquille O’Neil. “We won!” Pointing out the absurdity does not mean it shouldn’t happen. Personally, I don’t care one way or the other, it’s mostly just amusing. But it does tell us something. That we want to be a part of something bigger than us, a community, a team, a movement that means something, that does something of which we can be proud. People buy products because some pretty face or talented athlete endorses them. And even the humanitarian world is on this: I see the faces and read the words of cinema- and rock-stars on the plight of those suffering oppression and its hardships all over the world. And why? I’m not arguing that it’s not pragmatic, but it’s strange, too.

I see many faces of MSF, but for me, this week, it is Jochen, Ivan, Edith, and Jean-Marc (three of whom, incidentally, are Canadian). They did not win a football match, nor have they been shortlisted for an oscar nomination. But they did work non-stop for two weeks to fill the vacuum, to enable the provision of emergency health services in a large refugee camp in Eastern Chad. No newspapers picked up the story, of course. Can you imagine what would happen in Montreal if medical services were stopped for two days? What about two weeks? It would topple governments. It would be a national state of emergency. Well, it’s an emergency here, too, but look who did something about it. My team.

Steven Cohen Forensic Psychiatrist  team

19. Zanzibar, Tanzania, Africa

CAMH Steven Cohen fox.base

The ground moves here.  It may look like a patch of dirt, rubble or cracked concrete, but it you crouch down and just wait a few seconds, it starts moving.  Tiny ants doing reconnaissance, larger ones lumbering through, smaller red insects that look like pin-point spiders everywhere. Long things with many legs, beetles, and others start to circle and weave along some hidden meshwork that is beyond the understanding of humans.  Or maybe it is just random, chaotic radiation, turbulence, Brownian motion.  Scurrying like white noise.  There are no straight lines in Africa.

CAMH Steven Cohen crystal.spikes

I write “Africa” in the sense that most people that I have met use it here. Chadians will refer to themselves as Africans, as will Sudanese, Tanzanians, Kenyans, Congolese and so on.  It does not escape the Chadian pastoralist that he has a vastly different language and life-way than his neighbour in the next town, the village up, or over the lake yonder.  The word “Africa” resonates as a whole for the people who use it, and this is remarkable.  A few words of Arabic or Kiswahili, and millenia of trade, land rights, marriage arranging, brotherhood brokering, animal husbandry and herding, water-balancing.  These forces stretch a continent.

Shift ahead a few days.

A small place called Bwejuu.  South-East coast of Unguja, the main island of the Zanzibari archipelago, itself just off the coast of mainland Tanzania.  It was a seaside town, that forgot to close down, and moved at about that pace.  I’d arrived in the trough of low season, but met a few similarly wayward travellers nonetheless.  By day three I felt that if I was any more relaxed I’d slip into a coma.  Which was nice.  My mornings were spent snorkeling through the fringed coral reefs, and I awoke to the sound of small yellow birds that make small teardrop-shaped nests in the trees all around my bungalow.  Jeremiah, one of the Masai fellows working at the small guest house at which I stayed, asked me if he could take my motorcycle (250cc of Honda Baja glory) to the beach and ride it.  He had the energy and smile of a gleeful person, which struck me as a strange quality in someone carryone no fewer than three concealed blades under his flowing red garb.  As we went out to the beach, I realized that he had never ridden a bike.  But hell, neither had I until a week ago.  The problem came in trying to explain what a clutch is with twenty shared words!

Zanzibar is called The Spice Island, which is a misnomer. Sure, it may have once been the hub for trade in cardamom, lemongrass, nutmeg, chili and peppercorn, among others, but the food is of the blandest I’ve ever eaten.  Luckily this is well made up for, among many other things, by the spectacular views.  I had not bought a new camera by then, so I’ll just have to describe the scene.  Rough-hewn locally made tables on a white-sand beach.  Low-light candle in a corner.  The sun sets quickly and leaves a blotted underbelly of fiery reds and purples on the clouds.  It looked like hell upside down, and from a safe distance.  Lateen-rigged dhows are off in the distance, small wooden fishing boats that have a triangular shaped sail with a scythe-like curve that is masted close to the front of the sliver of a vessel.  Every image was charmed… that kind of a place.  I looked over to the right of me while I was sitting out there and saw about eight other people on the beach, seven of whom were taking photos.  This is a well photo-documented generation.  It struck me that it may be the case that more photos were taken of sunsets that one day than in all of the 19th century.

CAMH Steven Cohen happynazibus CAMH Steven Cohen MMman CAMH Steven Cohen selling dreams

My days on the island were coming to an end, though, and I had to run back to the capital, Stone Town.  This is, incidentally, also not really a meaningful moniker.  I suspect that it would have been more accurately called Smelly & Cracked-Concrete Town, but alas, that did not track well with focus groups.  The point, though, is how it is that one finds their way around this island, back to the capital.

These were the directions: “Turn right at the T-junction, then left at the second round-about, past the big “Foma” detergent sign, and when you’re close to town, you’ll see an intersection that looks like a platypus… turn hard left there…” and so on.  I was becoming a bit frustrated… the lack of street signage makes it difficult to know where you are, and where you should be going.  Over the past week, with no real destination in mind, this had bothered me none.  I had my rented dirtbike, miles of road and beach, and, of course, throngs of people everywhere to ask directions along the way.  And this is when it struck me… that image.  The one that comes at 5am, wakes you up, and just sits there.  You know the type, no?

Back a few nights.

Imagine a hard flat surface like a book or open hand slapping forcefully against another surface, that of a placid body of water.  Scale is unimportant.  Look at the streams of water that are jetted out from the sides, shooting outwards but connected by small tendrils, some thick and goopy, others impossibly thin.  A viscous crown of molasses-like mesh, curving in all directions.  Like in networks of veins just under the skin or on a leaf.  Patterns on wind-swept desert sand.  The mesh of a sponge.  The petrified pith of trabecular bone.

wadi.above huts.above1

This was the road back to stone-town, and the people were the network along which I would wind my way.

It started to rain, and I pulled over under the metal sheeting of a small hut where kids were selling fruit.  My clothes were soaked through, but it was warm enough to ward off the chill.  I bought a large papaya and ate the reddish-orange pulp while chatting with the kids in some broken pidgin of English and my ten Swahili words.  The boys were fascinated with the multitool leatherman that I had used, and took turns over the next two hours passing it among them opening and closing every knife and screwdriver.  Despite the rains, lots of bikes, motorized and not, whizzed by.  I waited for the rain to stop, pointed in one direction and said “Stone Town?”  To which the boys smiled and nodded yes, trying to curve their hands to the left, which was what I had to go on.  There are no straight lines in Africa.  But with a belly-full of papaya and the hot sun drying your clothes, this seems less important.

18. Power

The day that I left Chad a text message arrived an hour before hopping on a plane for my holidays (I write this from idyllic-but-obviously-not-too-distant Stone town, Zanzibar). The text message said that a fellow named Pascal Marlinge, the Head of Mission for an NGO (Save the Children, UK branch) had been shot and killed in a car heist a short drive from Farchana.



It left me sad and a bit numb; I write this with heavy hands.  I found myself trying to make sense of it. How could this have happened? And, inevitably, why did this happen? Why would someone shoot a clearly unarmed person exiting a clearly marked humanitarian vehicle with his hands in the air? And this is where my mind has gone while sitting in airport terminals, eating street food in the grungy Escape-from-New-York backdrop of Dar es Salaam’s Kariakoo district, and watching the waves foam up on shore.

The word that I keep coming back to is “power.” Several years back, one of my mentors in psychiatry casually said “there is only one type of power.” I am not sure if he’s right, but he’s the type of person that you listen to, and figure out how they came to that conclusion, even if you’ll disagree with it eventually. Over the years I’ve muddled around with the question of what it would be, this one power, if there was just the one. And what I’ve come up with is this: power is the ability for one entity to set the viability conditions for another. That is, one entity can effect a gross difference in the capacities, choices, and mortality of another entity. For humans, this would include, for example, a parent or state feeding their young so that their bodies can grow and learn; teach skills leading to more vocational choices; or the provision of basic health care so that a premature death doesn’t cut this potential all to shreds.

It is also, notably, the power at the end of a rifle, an apron string (families excommunicating members), an emotional outlash.  Images of tyrants always come to mind when I think of “powerful” people. Mussolini, Mugabe, Stalin, Pol Pot, Mao Zedong, Nikolai Ceausescu, Saddam Hussein. Basically what these guys did was whatever the fuck they wanted, and nobody could say otherwise. They were, and are, barbarians.

Lust, gluttony, avarice, sloth, wrath, envy, pride. These are the seven deadly sins, which may as well be a laundry-list of the manifest entailments of 20th century Western success. “Get rich or die trying.” Envy was used in the sense of “malice” in the fourteenth century, as in “creating equality” be taking or destroying that which someone else had… the vulgar side of jealousy: hate someone for having more or being more.

But this is here it gets complicated. I think that most of my cohort can rally against the despots, but what of the seven sins? It may be schlocky, but I think that TV is a sophisticated barometer of an ethos. While practicing up in the Canadian North, I had too much free time and a satellite connection, so I watched all seven seasons of The Sopranos. Hellava good show, and to my mind, there has not ever been a character as complicated as Tony Soprano. Somewhere along the way (maybe in the second season), I realized that this guy was a simmering psychopath (however pro-social). Enter “Dexter”, another TV character, who is a blood-lusting psychopath who “uses his evil powers for good,” killing “bad” psychopaths. Brilliant premise, but can you imagine the pilot being pitched twenty years ago? Not a chance. For 50 years, the bible of broadcasting was the Production code of motion pictures, and for 40 years or so up until the late 60s, it stated that:

“No picture shall be produced that will lower the moral standards of those who see it. Hence the sympathies of the audience should never be thrown to the side of crime, wrongdoing, evil or sin.”

You couldn’t even watch someone pretending to be evil!  As if just the perishing thought could shift the balance to the dark side.  I remember being timorous in medical school when I asked patients if they had ever had ideas of suicide or self-harm (a standard part of the psych exam, and for good reason). It was hard for me to ask the question, as I did not know what I’d do with the answer, or worse, that I’d throw their symathies to such an act.  It’s kind of absurd that someone’s going to say “wow, suicide, great idea! Never thought of it, but you’ve been a great help, doc.” I needed to gain experience with the idea of suicide in the same way that I have needed, in Chad, to become more familiar with ideas of genocide, mass displacement, and wanton violence the likes of which I had only read about, but never seen.

But what do we do, then, when we character-identify with Tony Soprano in some way but are also revulsed at the mindlessness of actual wanton destruction and death? This is not a rhetorical question. We talk about it, and the dialogue makes it more real. There is no answer, of course, but exploring it carefully may lead to a better ability to balance the essential urges of war and peace that wage their quotidian battles in us. Maybe we’ll even gain a better understanding of what power means to us, and use some of those superpowers for good.

So what, then, would be the luminescent side of power… how can we counterpose and salvage the beauty in willful and benevolent expressions of it? It would then be the exercise of might in capacity-building, the prolonging of life and heightening of health, all in the service of preserving the right for people to choose what they want to do. If freedom is some waffly continental breakfast, options and choice are the sustenance that sticks to your ribs.

MSF came out with a position paper of sorts called “The Chantilly Document.” It starts with a single line, before getting into two pages of text:

“The overall purpose of MSF is to preserve life and alleviate suffering while protecting human dignity and seeking to restore the ability of people to make their own decisions.”

In my opinion, Pascal was doing this. He was working away from his wife and two children, in an inhospitable place, quite likely for less pay, less stability, and higher job-related anxiety than he could have found elsewhere. Like so many people that I’ve met out here, they hold it together for some reason or another so that, in the long run, others will have more options. This character trait I call integrity, the exercise of which is strength.

It is apalling the abuses of power that I have seen in the past several months. The stories, the lives, the wounds physical and psychological. They track closely with the absence of wide, transparent, and consensus-driven means for accountability. With no accountability, it seems that power prevails over strength.

In the end, Tony Soprano got punted by his Shrink.  Strength prevailed after seven seasons:) I hope that Farchana does, too. We’re in our fifth year, now.


sorry, no pics.  My camera broke.  The fellow at the repair shop said “There is a lot of dust in here, where have you been?”

    “Chad, four months.”


17. Tea-time at the non-sequitur café

hamraNote that none of the following pictures contain patients, and all parties have signed written consent to have their pictures included in this blog.  Of course, parents signed for les petits.


Not sure what it was that helped me turn the corner, but after a couple of feverish nights and a loose string of, well, phlegmatic days, some energy returned!  Whether it was the anti-parasite medications, a few long walks under the mango trees, good days at work, or the regime of sun salutations, vitality creeped back in.  You need it here, too.  In the same way that it’s hard to remember the summer heat on your skin in the dead of winter, after a trudge through the dregs I’d lost sight of the joy in many little things out here.  So I thought that this is what I’d write on, or just show.  The things that you do that make this place fun…

Steven Cohen Psychiatrist Patrice.nerds

My good friend Jerry sent me a few care-packages of junk food and sundry, which included a bag of ring-pops, some original star-trek cards (odd), bubble gum tape, pez, and nerds.  This is a picture of Patrice, eating nerds for the first time.

Steven Cohen Psychiatrist Jochen.rope Steven Cohen Psychiatrist me.rope1

Jochen brought a slack-line from Swabia, and we’ve been practicing our tight-rope walking on weekends.  Seriously, you you make this up?

Make a Ouaddai-tini:
1) Go to Eastern Chad, in the Ouaddai region of the Sahel
2) Find hooch (locally called “diable” or “demon”)
3) Mix it with home-made Hibiscus juice

Walk pretty much anywhere and get accosted by jovial screaming tots

Steven Cohen Psychiatrist boys.fox.1 Steven Cohen Psychiatrist truck_work Steven Cohen Psychiatrist Kids.tree

Play soccer with them

Steven Cohen Psychiatrist volleyball.1

Kidnap a wee malnourished goat, nurse it back to health for a couple of days, and set it back out with it’s kin.  Be told by one of your staff to never touch local animals because the rules of Chadian ownership of animals is “more complicated than sex between ducks.”  Look confused.

Steven Cohen Psychiatrist hanamai Steven Cohen Psychiatrist Hanamai.2

Relearn the extent to which necessity is the mother of invention

Steven Cohen Psychiatrist IMG_0599

Read while listening to Ivan playing guitar under the mango trees

Steven Cohen Psychiatrist Ivan.guitar Steven Cohen Psychiatrist Ivan.guitar.1

Say hello in the morning to Fatima, a worker at the Nutritional Center, and her twins, Safi, and Safia

Steven Cohen Psychiatrist K.S.S

Say hello to Habib and Hamra, some of our MHS staff

Steven Cohen CAMH IMG_2207 Steven Cohen CAMH IMG_2200 Steven Cohen CAMH IMG_2176 Steven Cohen CAMH IMG_2156 Steven Cohen Psychiatrist Toronto IMG_2146 Steven Cohen Psychiatrist Toronto IMG_2096 Steven Cohen Psychiatrist Toronto IMG_1996 CAMH Steven Cohen Hamra

 Wonder after unfortunate abbreviations, MSFH Psycho for psychiatry

CAMH Steven Cohen MSFHpsycho

Say hello to the theatre group.  This week they presented a little ditty on “family planning.”  Later I learn that Zakariah has three wives and 19 children.  He looked disappointed when he learned that I had none of neither.  You either laugh or cry.

CAMH Steven Cohen theatre.troup

Uh, hello-moto?

CAMH Steven Cohen tent.moto

Walk through the camp and happenstance upon a volleyball game.  Be given a prized seat and asked if you want to help officiate.  Politely decline.


Hang out with Bienfait in the Health Center.

CAMH Steven Cohen Bienfait

Eat some lunch with the boys

CAMH Steven Cohen boys.lunch

Marvel at the need for vehicle-Bling, Ouaddai-region style.

Steven Cohen Psychiatrist Toronto bike_2 Steven Cohen Psychiatrist Toronto bike_1

Keep on providing good health care for free

Steven Cohen Psychiatrist Toronto definitely Steven Cohen Psychiatrist Toronto thatch_thorns

Wipe dust off your computer screen when you post blog entries

Steven Cohen CAMH dusty.screen

16. Fruit in a Bowel

“It’s not the mountain that wears you down, it’s the rock in your shoe.”

Steven Cohen Forensic Psychiatrist Steven Cohen Forensic Psychiatrist Steven Cohen Forensic Psychiatrist  ark.morn

It has been brought to my attention, most unceremoniously, that I have kept the blog more descriptive than personal, more playful than ranting, more academic than grit. That I’m telling the stories of others more than telling my own, and am committing the error that every shrink hates to make, but invariably does: I ask everybody else what they feel about this or that, and am not asking myself this question (or at least not writing about it). Point well-enough taken. How am I doing? Right now I’m starting to feel better, but last week I felt mostly flat, tired, and shitty.

Steven Cohen Forensic Psychiatrist  goundiang.pony.boys Steven Cohen Forensic Psychiatrist wadiFrisbee3 Steven Cohen Forensic Psychiatrist  David
When I arrived here among the standard questions I received (age, length of stay, number of wives and children, etc.) was “have you ever been to Africa before?” And even though I left when I was three years old, my having been born in South Africa was met with a genuinely warm inclusiveness; I was told that I have, and will always have, “un coeur d’Afrique,” or an African heart. I don’t know why, but somehow it fits in a goodly way… I feel a corporeal kinship with the soil, steppes, and people. The words “South Africa” smell of Jakaranda trees in blossom, of my grandparents’ Johannesburg flat, and large platters of freshly cut fruit. My bowels, though, are assuredly Canadian, and have for the past several months been treating me like an angry, antibiotic-crazed prostitute. And you can imagine that my skin, incubated for the past 20-some years in the halogen havens of classrooms and hospital hallways, feels about the same.

The rest of my body is, at times, not so thrilled either. After being here a month or so I got some odd rash on my palms, which I was told was probably from the harsh soaps or maybe dyshydrotic eczema (from sweating too much). Either way, over the following couple of months the skin hardened and then peeled off, but I was just glad that it wasn’t itchy anymore. Some problems with bed-bugs, a painful tooth (for which I went to the capital to see a French dentist who never arrived, so I just came back to Farchana), and some back pain rounds out my list of gripes. No, add the large spiders (like the size of your fist), the fact that a few weeks ago my computer broke (hence no pics on the last few blogs), that the MSF-provided shared computer has a screen that flickers epileptogenically, and that my blog is being censored in ways I don’t understand, and you get some sense as to the frustration. If I were back home, I’d get the computer(s) repaired, take a long walk, catch a movie, rant in-person to the censor, read a dour blurb in The Economist and promptly forget about it, partake of a soul-soothing smoked-meat Schwartz’s combo, paint, and sit across from a good friend or two and, while a smile and beer endure, sing the blues.

Steven Cohen Forensic Psychiatrist  brain

For the first time since arriving, I felt tired in my bones last week. It’s been three months here, and I have since mostly marveled, but I recently found myself wanting to not have a 6pm curfew, not live in a 43ºC-in-the-shade dust-bowl, eat some standard fare, crap normally, and otherwise read for a week. I awoke one morning and felt *hesitant* about going into the camp and seeing patients. The crush of suffering was daunting, and I just wasn’t sure if this would be the day that I’d lose my grit and have to go back to the compound, or, dare the thought enter, just leave altogether. Worse still, that the empathy buffer was too thin and I’d show frustration with my patients or colleagues. Everybody has parts of their job that are uniquely hard, and for me it is working with children. It’s a cliché, I know, but the children save you out here (followed closely by your team and patients). I spend a lot of my day playing with tykes who initially yell out “ok!”, “ca va?” or “donne-moi un cadeau.” But when they’re mute and catatonically frightened after some horrific incident, it stays with me in a way that other patients don’t. Images of Fatna sitting on the mat with a perplexed and curious disposition still arrive in my sleep, when I walk from one health center to the other, or sit down to eat; her story, and so many like it, of the sticks and death, isolation and fear, are present.

I’ve always felt that it is a good thing to follow dreams, in part because they’re inspiring, but mostly because they never give you what you think they will, and you get a whole lot else in the bargain. Sometimes good things, sometimes less so, but it’s definitely good to figure that out sooner rather than later. This isn’t a nod to jadedness… it’s just what one finds when you pay attention to the appearance of things. And so it has been coming out here, to Chad, to Farchana. Last week, in the icy clarity of a protracted and jittery malaise, I started to recognize the pleasures that have been earned by the boys playing soccer with long-destroyed balls or the frustration in the eyes of an old man who knows his children will not be brought up in a political state that could in any way be confused with a meritocracy. Hope is an emotion that operates in accordance with the law of gases: it will expand to fit any container in which it is put. Last week I felt it to be thin, and I wondered, selfishly and somewhat ashamedly, how I would survive in this rarefied environment. If hope is some ether of self-preservation mixed with motivation, it is icy clarity and rage that focuses it like a lens. This helps… to know in that vital way that things here need to get better. It counters the adaptive instinct that can bring with it a well-intentioned but eventual complacency. Well, that and another course of antibiotics that hopefully will get the bug that ails me:)


About 5 years ago I was living on the plateau in a cavernous unfinished loft on St. Laurent, a couple floors above a bar/billiard hall called “Le Swimming.” The place comfortably slept five; at that time there were seven. The plumbing had been done by my buddy and loft-mate Adam who was a master of approximation and invention when it came to fixing things around the apartment. But with all the engineering capacity at his non-negligible disposal, the plumbing in the bathroom needed a better system than the rusty nozzles and showerhead. So we hopped into a beat-up MG that had recently had it’s entire bowels removed and put back in, and head off to where we could exchange money for said necessary product. The guy at the store showed us some pressure-balanced gizmo that adjusted hot and cold water in one nozzle—I’d imagine almost everyone reading this has one. But myself being a first-year psych resident, and Adam being in the throes of an interminable PhD in biomedical engineering (he recently finished, incidentally, and is off to MIT for a hopefully less-interminable post-doc), we decided to hit the hardware store and make do with a cheaper, non-rusty but still-crappy system. This is when the guy in the store, overhearing our conversation, said “don’t buy anything that’s not pressure-balanced, you won’t be happy with it.”

Fast forward to last Tuesday in the mobile clinic, about 25 miles southwest of nowhere, 7 pm, pitch dark on one side of the starry-night horizon, and opposite the last remnants of a faint under-lit glow just visible behind the mountains in the West. The shower was, as are most things here, built with an economy of resources and time as much as plastic sheeting and irregular-shaped bricks and crumbly mortar. So there’s the shower, a pillar of bricks in one corner of an open-roofed, plastic-sheeting-enclosed space slightly bigger than a phone booth. A black jerry can with a refilling hole cut out of it’s top sits on the head-high pillar, and a 2L plastic water bottle has been grafted onto the side of the can, with a rudimentary plastic spigot to adjust “water flow.” The water still hot from the day’s heat, I found myself wondering if the skin on my arms was dark because of the sun or the layers of dust and sweat and more dust. I think it was the best shower that I ever had.

Steven Cohen Forensic Psychiatrist hitsuyo Steven Cohen Forensic Psychiatrist  hitsuyo.spigotSteven Cohen Forensic Psychiatrist walkabout.tree

When did I forget this? That it’s not some fancy nozzle that makes a good shower. It’s being dirty after an honest-days work. If but only to learn that again I would have come back to Africa. Tomorrow is Monday… a new week and I’m happy to be here, but I suspect that I’ll also be well ready for that vacation that’s coming at the end of the month.

15. The Marabou Picnic

One of the more conspicuous aspects of psychiatric work is that we deal with syndromes and diseases whose defining elements are often invisible. You can’t see a “depressive or anxiety disorder” in any definitive way, and would usually have no way of telling whether the person beside you on the bus or at the market has schizophrenia. You could say this for so many ailments, but few medical disciplines so completely lack genetic or physical markers, biochemical tests or imaging technologies that we can deploy to confirm or deny our suspicions. We listen, ask questions, and listen some more, and eventually fashion a clinical story that makes sense. And this brings us to Farchana camp, a veritable village of 20,000 Sudanese refugees who have for generations relied on “marabous” as the healers and vessels of a long history of orally transmitted knowledge. A marabou, of course, has his or her their own way of taking these empirical facts such as “feelings of sadness,” “decreased appetite,” “nightmares,” or “confusion” and making sense of them. About four or five years ago, when hundreds of thousands of Sudanese herders, farmers and nomads fled Darfur, they brought their practitioners and practices with them. Along came MSF, shortly there after, and the two healing systems have worked side-by-side, in a way, but with almost no contact. You gotta wonder, who are these people? What do they do and why? And what do they think of us? So I decided to ask.

After over a month of planning and a broad invitation, we received this week about 20 “healing” marabous to our mental health services. “Marabou” is the term given to Sudanese traditional healers, and could be translated into “teacher” in English, or maybe more accurately into the way the Japanese use the term “sensei.” It refers to someone who has attained mastery in a field, and uses that mastery to guide others. I wrote previously about three subtypes of marabous: 1) Imams, or scholarly religious leaders; 2) Faux marabous who have no real training, and practice their charlatanism on the credulous; and 3) Healing marabous, who have apprenticed in the therapeutic use of Koranic verse, botanicals, insects, small animals and their by-products for ingestion or ritual practices. When asking around, I found that these healing marabous are usually venerated by the Sudanese, although some scoff at them as well. Either way, well over half of our patients see marabous for the same symptoms for which they come to our mental health services, sometimes in parallel and sometimes after one or the other system has “failed” to meet expectations. Marabous were in this Sahelian region of sub-Saharan Africa well before MSF showed up, and’ll be here long after we’re gone so I figured that it would be clinically useful to sit around a table, munch on nuts, drink sugar-tea and start a dialogue. And, yeah, I thought it could be kinda trippy, too. This is what happened.

Pretty much everyone arrived at once, and I was giddy to have the opportunity to meet them. After some introductions and polities, they were informed of our “rule” in mental health services, that “anyone can say pretty much anything at any time, and nobody needs to put up a hand to request to talk… if people talk at the same time or disagree, it is like family.” For some reason, this seems to set the right tone here.

Who do you feel is best treated by marabous?

The room was silent for about ten seconds, which seemed like a long time. Most of the group, which consisted of men in white Jalabias (long shirts over a fair of pants), and one woman wearing a bright orange stole, were studiously avoiding eye contact; there was no “predetermined leader” here. I was going to paraphrase when one fellow in the corner promptly said that for every person that comes to him for treatment, he sends them to MSF’s Health Center for a first-pass assessment. And only if MSF’s shot at things is found ineffective, the marabou will then offer treatment. I double-checked to make sure that I’d heard correctly, and then polled the room to see if this was standard practice or a one-off thing. No dissent… nodding heads and few more statements indicated that this was the norm. Wow. It’s possible that we had a biased sample of marabous, and the ones who were less enthralled with our services did not stop by for tea, but again the group said that this was not the case; they liked the fact that we were there, and trusted our services. Marabous come to MSF all the time, they said, we’re “good for some things.”

What ailments are the most common for which people seek their services?

“For invisible things” was the answer. The list includes joint pain, back pain, change in eyesight, bone pain, infertility, head-ache, insomnia, stomach troubles, malaise, and fast heart-rate (what I assume meant palpitations). This is basically a list of non-specific and chronic symptoms for which there is often no good diagnosis nor treatment in the allopathic Western medical system (e.g., a Canadian hospital). One fellow added that for “nightmares” he’ll just jump straight in and forego the “referral” to MSF.

So what does a marabou offer?

The first and by far most commonly used treatment is translated as “black water” or “sacred water.” A small object shaped like a star is placed in the Koran at a random page, and when the verse that it touches is read, it hints at both the diagnosis and treatment. On a wooden board, this verse is written alone or with a few others. The ink used to write the words is scraped off and put into some water, and mixed with a specially made concoction of herbal, animal or mineral elements, and is then drunk by the patient. The most common examples given were roots and ground-up insects, but the phrase “it’s complicated” came up a few times. The marabous wait two days and then adjust the concoction depending on the result of the first trial. One marabou suggested that if two trials do not work, or if the symptoms change, then the person is sent back to MSF, but others had a few other possibilities for treatment: A beaded necklace could be used to direct the prayers of many Imams, if need be; or concoctions could also be applied to various body parts, although I could not really understand which ailments routinely called for this approach. There is also another ritual whereby the tip of a ram’s horn is inserted under the skin of the chest of a man who has heart troubles, and some “bad blood” is removed. A specific ointment may be placed on the skin, and the quality of the scar indicates the success of the treatment and an indication of the quality of the remaining malady. These were some of the examples given, but there was not enough time to explore much more into their local significance, unfortunately.

What happens if the service is ineffective?

Success, I was told, is guaranteed or you get your money back. Initial payment can be cash, some food, or, if it’s a complicated ritual, a goat. One question that I’m still very interested in asking at a subsequent meeting is “what counts as a positive outcome?” But we were running out of time.

We finished the tea and nuts and asked at the end if there were any comments or questions that the marabous had for us at MSF. The only one that came was “how can you afford to do this?” MSF runs a big operation in Farchana. We have seven ex-pats, over 50 national staff, and over a hundred Sudanese employees (like the counselors and community health workers with whom I work most closely). Apart from the health center, there is a busy maternity center and nutritional center, and, of course, our mental health services, which has about 500 “patient visits” per month. Over 85% of all the births in the camp happen in our centers, which run 24 hours a day. And if the job is too big for us (we don’t do surgery here, for example), then ambulances are available at all hours to take patients to a nearby town where there is an MSF team with surgical services. And, of course, all of this is free. So how we pay for this is a fair question, but it still came as a surprise. I’m Canadian, and free health care is what we do… the idea of anyone paying for health care seems distasteful. But it’s not taxes that have subsidized the exporting of socialized medicine to the eastern border of Chad, and since I don’t know how to say “good will” in French, I told him the other commonly-used phrase in our mental health clinic: “we’re all in this together.”

14. Trauma, Empathy and Counselling (Part 2)

Steven Cohen Psychiatrist Toronto huts.above3 Steven Cohen Psychiatrist Toronto huts.above2 Steven Cohen Psychiatrist Toronto mango.buckets

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:

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.

Steven Cohen Psychiatrist Toronto Steven Cohen Psychiatrist Toronto IMG_2198

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!

13. Trauma, Empathy and Counselling

(In the following story, names and minor details have been changed for confidentiality).

Steven Cohen CAMH Issakha.Me.block.2

Ahmed, one of the national staff pulled me aside today.  He hesitantly asked if he could speak with me about a member of his family who was “traumatized,” and specifically how he could help.  This is the story that was told to me.  Several weeks ago, Amane, his 32 year-old first cousin was fleeing violence in N’Djamena, the capital of Chad.  Fighting had escalated quickly and within 24 hours parts of the city were destroyed and looting and random violence were rampant.  Amane, her husband and their two children decided that it would be safer to flee at night, but she became separated from her husband and continued to the bridge to Cameroon with her two children, a 5 year-old daughter and a 9 year-old son.  Many people left N’Djamena for the villages outside the capital or fled to neighbouring Cameroon (UNHCR registered over 30,000 Chadian refugees).

I imagine that the 500 metre-long bridge was a welcomed sight.  There are three bridges across the Chari river, and the closest for Amane was single-laned, large enough for one truck and a few feet on either side.  Enterprising boat-owners were cashing in on the chaos, charging people up to 10,000 CFA (CAN $24) for passage across the short channel, but few could afford this and opted for the walk.  Stories tell of the flood of frantic people pushing to get by the abandoned vehicles to the other side.  The walk that normally takes fifteen minutes took up to three hours.  I’d like to think that it was to avoid the danger of her small children being trampled that Amane steered toward the side of the bridge, but it was probably bad luck and the madness of the crowd that pushed them against the rails.  And it was in this same madness that her children fell over the edge, into the water about 20 feet down.  There were no lights at all and when they fell, there was probably no way to see them in the dark water.  Ahmed tells me that Amane tried to jump in after them but people held her back, and she finished crossing the bridge not knowing whether her children were dead or alive.

It’s been over a month and they have not been found, and Amane has been taken to live with her husband’s extended family in a quiet village far from the capital.  I’m told that she sits with others at meal-times and looks as if she is “in a daze.”  She doesn’t talk, eat, or make any emotional contact most of the time, and when children are playing nearby, she often breaks into tears and has to get up and leave.  At night Amane is not able to sleep for longer than an hour; she wakes up crying, calling out the names of her children.  In the early morning she often informs her family that she needs to go to the market “to see her kids,” but given that loud sounds and sudden movements cause her great distress, a trip to the market would be quite difficult; she has not been able to leave the house for weeks.  Soon her sisters will visit, and the family hopes that this will help.

Steven Cohen CAMH door

Of course, one cannot make a diagnosis without a full in-person assessment.  But it does appear that Amane may suffer from a constellation of symptoms that is labeled in the Western psychiatry manual, the DSM-IV-TR, posttraumatic stress disorder (PTSD).  The label in-itself is not so helpful, and there have been other names of syndromes that collect and organize symptoms of re-experiencing, numbing, and hyper-arousal in other ways.  The diagnosis is a bit of a misnomer, too, as in many situations the threat and actuality of trauma continues, so there is nothing “post” about it.  But what is PTSD? And how does our understanding of its origins lead us to treat psychological trauma?

PTSD is a malady of memory.  To function well, we need the capacity to remember some things and to forget (or dull) others.  It is good to remember that touching a hot stove is dangerous, and in a near-literal way, this memory is seared into our minds by virtue of the pain—and emotional arousal—of the moment.  But we need to dull this memory allowing us to attempt to use the stove again, albeit more cautiously.  In PTSD, this natural dulling of the emotional tone of a bad incident is thrown off, and the smallest sound or sight takes you right back to the pain; in a real sense, every night since, Amane may be back on that bridge, with all the horror, helplessness, and loss.  The adaptive “high-alert” vigilance that helps her keep safe when cooking on hot stoves has turned against her, like a disease of adaptation, and now exhausts her resources.  Any loud sound or unexpected movement can be perceived as a threat, and it is this distorted threat-appraisal that must be unwound.  In a manner of speaking, our sense of who we are (our “self”) is bounded by the ability to remember and to forget, and if one is compromised, we lose who we are.

The question of what can be done to help Amane and so many other people who continue to suffer in this way, must be split up into two questions: 1) How can we prepare ourselves for this type of calling, and 2) What can we do to help?  The rest of this blog will answer the first question, and the second question will be the subject of the next entry.

1) Preparing to listen

In blog #11, I gave an account of the narratives of Fatna and Ibrahim, which were quite emotional for me.  A few days later, a friend from Montreal wrote a comment asking what we do in our mental health team to protect against “vicarious traumatization,” which means in this case a counsellor being themselves traumatized by hearing such difficult stories.  It’s a good question.  One has to balance empathy with self-preservation, while doing honour and justice to the integrity of the patient, his or her narrative, and the attendant empathic emotions that they evoke. A therapist needs to be able to withstand the brutal side of empathy to simply bear witness to it.  In psychiatric terms, the ability of a person to do this is their “negative capacity.”  In my opinion, the role of a good therapist is to facilitate a surface upon which meaningful communication can flow.  And we have to prepare ourselves for a torrent of words and emotions… whatever may come, a counsellor must be capable of simply letting the moment happen.

As you can imagine, discussion among our team of counsellors gets heavy at times.  We go from laughing about small things to presenting difficult cases to the group and getting support and counsel from each other.  We talk of our patients, and of our experience of being with them. Once a week, two hours are set aside for this exact purpose, and other “supervision” times are available, too.  (Of note, 24-hour psychological support is available for MSF staff.)

Steven Cohen CAMH woman_digging

It quickly becomes clear that fear and pity can be dangerous if they lead to a paralyzed empathy and inaction.  Through these discussions, in a number of ways, we become more familiar with the pain of suffering, so that we can contain the harshness of it, rather than have to dissociate, isolate, or destroy within us that which resonates with it.  This does not minimize the horror of the situations or stories that we witness and feel, but it increases our negative capacity, or ability to withstand it. And by doing so, we can attend more closely to our patients rather than to ourselves.