Malnutrition and psychotherapy: MSF experience in the Palestinian territories

Summary of published paper^*

In 1996 MSF set up a mental health programme in the Palestinian territories concentrating on the southern part of the West Bank. The work was carried out in conjunction with Terre Des Hommes (TDH) who were running a medical programme including weight monitoring of children combined with nutritional advice to carers.

Malnutrition in the Palestinian territories was mostly attributable to lack of food, costly and poorly executed infant feeding practices using formula milk and problems in the mother-child relationship. After three months of observation MSF set up a programme of psychological support for mothers and children as certain mothers were finding it very difficult to re-nourish and care for their malnourished children. The premise of this programme was that mothers were depressed due to collective phenomena, e.g. early marriage, repeated pregnancies, the social environment being disrupted by the conflict and that women were isolated and had little by way of support networks.

The MSF intervention was initially based on individual interviews at nutritional centres with a female psychologist, followed up by home visits. In January 1998 MSF began to conduct research by focussing more on the nature of the bond between a mother and her malnourished children and on methods of re-establishing this bond. The hypothesis was that the malnutrition seen was partly due to modes of interactive behaviour which were characteristic of attachment disorder within the mother-child dyad (pair).

Mother-baby dyads for the research were selected on the basis of the following conditions: moderate or severe malnutrition, a dysfunctional mother-child relationship and children aged one month to two years. The dyads were observed over a period of one year and received psychological counselling while the children continued to have growth monitored.

It was observed that care and attention for malnourished children during feeding was not given the same priority as 'well-nourished' children, e.g. the child was not fed on demand and feeding times were irregular. The behaviour patterns observed were also sub-optimal in terms of holding, visual and tactile interaction. For example, in holding the child would be resting against its mother's stomach but not held in her arms. Very often the mother made no attempt to wrap her arms around the baby or to support its head and neck. Also, there were no reciprocal visual exchanges between mother and child - which may have been because the mother completely enveloped the child in the carrier blanket or her Islamic chador. Similarly, mother made very little use of language to communicate with the child. The vocal interaction was mainly tongue clicking and whistling noises intended to stop the baby crying or keep time with the mothers rocking movements. Tactile interaction through skin to skin was also extremely limited. There were many other behaviour patterns which were not observed in 'healthy' mother-baby dyads.

The main findings of the study were that:

• Failure to hold the baby during feeding appears to be a significant mode of behaviour amongst mothers in the study. This possibly reflects the way the mother herself is unsupported by her own family circle and cultural group.
• The mother's physical and psychological defences were weakened by the political, social, economic and family environment. Her suffering is then expressed by symptoms of depression leading to inadequate maternal care and attention.
• Through its food disorders, e.g. anorexia, the baby reflects not only the mother's problems but also those of her whole family and Palestinian society.

The authors also claim that through this study MSF have learned the importance of evaluating:

1. the quality of holding, as well as the three other levels of interaction (behavioural, affective and imaginative) in mother child dyads and,
2. the context, in order to understand vulnerability factors at the root of the maternal problem, e.g. conflict, trauma and acculturation

The authors assert that these observations have allowed MSF to refine techniques of therapeutic care for malnourished children and to work towards restoring the maternal function and the attachment bond in situations such as those found in the Palestinian territories.

^*Fernandez. S, Lachal.C and Moro. M (2001): Malnutrition and Psychotherapy, the MSF Experience in the Palestinian Territories. MSF Medical News, volume 11, No 2, August 2001, pp 77-80