8. Mental Health Services # 1

[This is written from the MSF compound in Abéché, whereto I’ve been partially evacuated.  If you’re following the news, you know that things are a bit hairy here in Chad.  Rumours abound, but I have no good sense as to what’s  happening.  From the compound we can hear tanks, helicopters, jets, and so on.  But no gun-shots.  This blog isn’t really the place to be seen to be monitoring or reporting on governmental ongoings, as that path leads to jail.]

http://www.economist.com/node/10653481?zid=309&ah=80dcf288b8561b012f603b9fd9577f0e

Steven Cohen CAMH | new.sheriff

The Head of Mission (HoM) has, for the time being, restricted all movement in town or anywhere else, but I got permission to quickly scoot off to the nearby UNHCR compound where they have internet.  It’s basically a lock-down-and-wait scenario. The HoM and the rest of the management team continue to work, but the evacuated expats are in limbo. Of the Farchana-team who would have to be evacuated in the case of a crisis, about half went a couple of days ago, myself among them. This was so that if need be, the rest could be moved more quickly, in a single plane-trip. One incident in Farchana camp yesterday led to a gendarme (armed guard) at the camp being shot and killed when he tried to intercept the attempted theft of a truck. Two trucks were stolen (from another NGO). I don’t know the details. Of the persons that were evacuated from Farchana and other projects, about half were evacuated further to Cameroon. Some are providing emergency medical care there, and other are taking their much-needed vacations or early endings of their missions. I decided to stay in Abéché so that I could return to my project ASAP, and so that if there was any need of psychiatric services here, I would be around.  But to do psychiatry in a war-zone, you need a modicum of stability and some planning, neither of which is in place. I’d need a translator (or two), and then a means to integrate services into the existing network, which is complicated. So it probably won’t happen. But that’s why I’m still here and not in Cameroon… maybe it will come about, and I can get to the local hospital and do some work.  Current efforts are mainly directed at surgical interventions. I wait, chat with the other “partial evacuees,” play scrabble (against the computer, mostly), and listen to BBC Africa on shortwave radio. There’re the details, and below is the blog I’d been waiting to post. Waiting because I wanted to see more patients and get a better feel for things, but I figure I’ll put the first part out now and see where the chips fall later. Hopefully it has pics attached, but if not, they’ll be added later).

Let me introduce you to the Mental Health Services (MHS) team.

Steven Cohen CAMH | IMG_1990

The team is nine persons, of which I am the most recent addition. From left to right: Issakha, Habib, Djamillah, Hamra, Fatna, Habib, Nafisa, Kadidja, Rauchaia and Aicha. (The picture captures well the bright smiles and colours of our team.  There is a bright spirit to the group.)

Habib and Issakha are the two supervisors, with university training in psychology, and a host of languages at the ready. Both are Chadian nationals, and have been working with MSF for about 3 years. Issakha is technically also my full-time translator, enabling me to speak to the refugee population who are generally unilingual Masalit speakers. The women are Sudanese refugees who have been hired as daily workers or “journaliers” by MSF (because a contract cannot legally be given to a refugee), and they speak Sudanese Arabic, as well as Masalit. I have to speak to the counsellors via translation by Habib or Issakha. The main criteria for hiring the counsellors, as I understand it, were language ability (written and spoken), motivation, as well as that elusive element of “psychological mindedness.” That is, they’re good listeners and have an interest and aptitude for addressing social problems.

On day one, I was thrilled to finally meet the team and get down to business! I think that they were happy to see me. In part this was based on the fact that when Habib shook my hand, he didn’t let go for about five minutes, and smiled a lot. I didn’t understand half of what he said (my French bites, and the accent here will take some getting used to), but it seemed rather friendly. As we went around the circle, each counsellor introduced herself, and they told me where they were from in Darfur (each from a different city), how long they’d been in the camp (about 3.5 years give or take a year), children (alive and deceased), and their marital situation (how many other wives their husbands have).

It was a friendly and inviting group, despite the language barriers and the fact that the women took an hour before they would sustain eye-contact with me for more than two seconds. I had one main question for the counsellors on day one: what problems do people bring to mental health services? And this is the list of the problems, in the order given, and with a bare minimum of exploratory questions by me; I just wanted to see what was salient to them:

1. Violence against women at the hands of military (of all types) and Chadians when they leave the camp to find fire-wood for the hearths and feed for the animals.

2. Domestic disputes between couples, involving money, fidelity, multiple marriages, substance abuse (lots of bootleg alcohol), and everyday things (parenting styles, communication, unemployment, theft, etc.).

3. No jobs for men, which puts strain on everyone. When I asked what the “presenting compliant” was in these cases, I was told that men cannot earn money to pay for the marriage dowry, and were not happy. They arrive with shame, and often with guilt at having committed crimes to try and rustle up some valuables. This often involved the theft of an animal, which is a big deal around here.

4. School refusal. In September, some kids refused to go to school, so group psychotherapy sessions were started and eventually all were convinced to go, I was informed.

5. Unwanted pregnancy. This was between young lovers who were “not yet married,” as it was described, or by young women who had “older men who buy them things.”

6. “Mental Health Problems.” This group were called “victims of violence,” such as being attacked or seeing someone being killed in front of them. And the most frequent presenting complaint was “insomnia” or “nightmares.” I was informed that about 30% of people seen at the mental health services present with this.

7. “Social problems.” Refugees need identity cards that also function as ration cards for their families. Often they cannot navigate the system, and come to MHS “with stress.” As well, financial problems and shortages of food were discussed here, and the gist of the discussion is that the counsellors provide some talk therapy, but mainly just help them connect with the right place to get through the red tape of administration, or to offer emergency provisions.  This would be a pragmatic social work approach, and MSF has hired for the mental health team someone whose primary task is to attend t these complaints.

Over the course of the week, I saw five patients in person, all of whom were those brought to me by MHS staff who were not sure what to do, or just wanted a second opinion (mental health people do this a lot in Montreal, too).

[Thanks for the comments.  If blog-readers have comments, suggestions, musings, please write them. I will try and respond when I have more than twenty minutes at a (relatively slow) internet terminal.]

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