Mental health in emergencies

Summary of published papers^1,2

Field Exchange has previously run articles on the need to address the mental health of war affected populations and to consider the possible link between mental health, economic well being and future food security. The importance of mental health care during and following conflict appears to be increasingly recognised by humanitarian agencies. For example, during 1995 in the former Yugoslavia, 185 mental health projects were being operated by 117 organisations.

A recent article in the Lancet addresses the issue of improving psychosocial survival in complex emergencies. It illustrates how mental disorders are difficult to measure and hence there are few robust data that quantify their prevalence in war-affected populations. Additionally, there are inadequate comparative data on the prevalence of these disorders in stable low-income countries.

Many mental health programmes have provided counselling services based largely on tools developed in a western cultural context and have focused on the prevention and treatment of post-traumatic stress disorder. Recently these services have been criticised for focusing on the medical disorders of individuals and failing to recognise that war and displacement are collective experiences that warrant community responses.

Some researchers urge aid agencies to focus on supporting the adaptive responses of communities to deal with widespread grief, anger, loss of identity and helplessness. These emotions are normal human reactions that are most commonly addressed through religious and cultural rituals, attention to continued economic survival, and family cohesion. Ensuring a lasting peace is probably the most effective external intervention to support community restoration. Others may include support for rituals (such as reburials), employment, restoration of governance and a process to ensure justice.

Public health programmes are often initially overwhelmed by the task of reducing morbidity and mortality from infectious disease, malnutrition and injuries. Thus, a phased approach to mental health would include an assessment of mental illness using culturally appropriate tools, a study of community coping mechanisms, support to the community adaptive systems and home-based care of the mentally ill through local community based organisations.

An example of community based mental health support was described in the same issue of the Lancet, through the work of the Amani Trust in Matabeleland, Zimbabwe. This local, nongovernmental, organisation rehabilitates survivors of torture and of organised violence in the western half of the country. Until 1987, civil war had raged in western Zimbabwe since independence, during which time 10,000-20,000 people are estimated to have died. The Amani Trust initially approached communities expecting to offer counselling services, in keeping with the western expectation that post-traumatic stress disorders would be the most prevalent problem. However, it proved better to move away from one-on-one psychotherapy and instead, use traditional community conflict resolution, belief systems and public truth telling to restore social fabric after community destruction.

This community approach is reflected in Amani's involvement with exhumations. Ancestral spirits are hugely important in regional belief systems in Zimbabwe. For an ancestral spirit to protect a family, it needs an honourable funeral and a ritual in which it is officially inaugurated as an ancestor. The main request made to Amani by community leaders and families in rural districts has been for an intervention to appease the aggrieved spirits of people who had been murdered and buried in unacceptable graves. This is how Amani first became involved in exhumations and for four years since, has been working with the same communities in five adjacent villages in Gwanda district. Using longitudinal case studies of communities and families, Amani assess the consequences of exhumation and reburial from cultural, psychological, individual and group perspectives. The overwhelming perception of families and community leaders is that the process had been both healing and progressive.

¹Toole M (2002). Improving psychosocial survival in complex emergencies. The Lancet, Vol 360, September 14th, pp 869

²Eppel S (2002). Reburial ceremonies for health and healing after state terror in Zimbabwe. The Lancet, Vol 360, September 14th, pp 369-370