Kosovar refugee children making drawings about the experiences they lived through in an MSF mental health project in Albania. © Roger Job

Doctors Without Borders/Médecins Sans Frontières (MSF) has for more than 30 years responded to wars, famines, epidemics, and natural disasters by providing emergency medical care to people in crisis. However, it was on the killing fields of Bosnia in the 1990s that MSF volunteers recognized that it was not enough to meet the physical needs of people caught up in conflict. The psychological and emotional scars of war –wounds that may continue in people's minds long after the fighting has ended– were being neglected.

"What do you do if there is enough food, but no one wants to eat?" asks Kaz de Jong, MSF's mental health advisor. "Sometimes people are unable to eat because they no longer want to live. They may have witnessed the killing of their family."

From 1993 to 1997, MSF implemented a comprehensive program to address the emotional trauma of thousands of people, including children, affected by the Bosnian war.

"I would like a new house like a castle and I would like the people who destroyed it to be punished by making them rebuild a castle," said Matja, a 7-year-old Bosnian girl who lived in Croatia during the war, in response to a question from an MSF psychologist. "I also want them to give me back the boat they stole. I want the little brook next to my house, the waterfalls, and the things I had in the house. I want my grandmother to come back alive from Bosnia."

The Bosnia program was a departure, in both size and scope, from earlier mental health interventions MSF had undertaken in the Gaza Strip, Uganda, and India. Under de Jong's coordination, MSF established 10 counseling centers in Sarajevo and trained 70 local counselors to help bridge the cultural divide between MSF volunteers and the Bosnians they aimed to assist.

Training local counselors, which is at the heart of MSF's mental health approach, was also crucial to building up the community's capacity to deal with the ongoing conflict. Through a mix of individual and group counseling the program aimed to help Bosnians restore the bonds among family, friends, community, and society.

MSF used radio programs to teach Bosnians about emotional reactions to traumatic events. "The stigma of weakness, the acknowledgment of suffering, and the shame that so often surrounds traumatized people became a collective experience," says de Jong. The program reached more than 10,000 people.

From Bosnia to Gaza to Sudan

Since the Bosnian war, MSF has conducted mental health interventions in more than 40 countries. Generally, MSF's mental health volunteers provide psychological education and train local counselors to assist their neighbors. They also bring home-based care to people too traumatized to leave their homes and establish walk-in clinics.

With mental health programs operating from Colombia to Nepal, MSF volunteers design their interventions to account for cultural differences. In Sierra Leone, for example, MSF volunteers found the greatest success using group therapy for people affected by the country's civil war. But in Chechnya, people were reluctant to speak within groups and favored one-on-one sessions in formal health structures, according to MSF's Kaz de Jong.

"We made it less formal in Sierra Leone," says de Jong. "The sessions often took place sitting under a tree. People would walk by and join the group."

Since 2000, MSF psychologists have conducted counseling sessions for families trapped amid the ongoing conflict in the Palestinian Territories. During an Israeli offensive into the Gaza Strip in October 2004, MSF mental health teams were denied access for several weeks to the families they had been treating.

Indeed, one of the greatest challenges of treating emotional and psychological trauma in conflict zones is the risk that patients will become separated from their therapists. For this reason, the counselors and therapists focus their intervention on enhancing psychological self-help mechanisms.

Integrating Mental Health Care

In most cases, mental health specialists work within MSF's existing emergency medical programs. In Darfur, western Sudan, MSF psychologists are training community health workers to identify and support survivors of sexual violence.

"Women are afraid to tell their husbands they have been raped since they don't want them to go and fight," a 20-yearold displaced woman in West Darfur told MSF. "They only say they have been beaten. But men are fully aware that their wives have been raped."

The health workers tell the people living in displaced-persons camps about the opportunities for psychosocial care and refer women for medical treatment.

In therapeutic and supplementary feeding centers, volunteers are trained not only to focus on the malnourished children but also to look for signs of emotional trauma in mothers. The most telling signs are mothers who no longer care for their children–who do not hold them anymore and hardly interact while feeding them.

Volunteers try to rebuild the motherchild bond by addressing the mother's psychosocial needs through counseling groups or helping the women get back to their daily routine from before their displacement, like making clothes or cooking meals.

Supporting AIDS Patients

Mental health care is an integral part of MSF's HIV/AIDS-treatment programs. All of the 23,000 patients receiving antiretroviral therapy in MSF clinics and hospitals have access to psychosocial support.

"But we need to improve this support for people living with AIDS," says de Jong. "The incidence of depression is very high among this group. All end-stage HIV/AIDS patients suffer from dementia or conditions seen in much older people. We need to develop strategies to help our patients cope with these conditions."

Coping with Natural Disasters

An MSF Psychologist listens to a traumatized a woman in Gonaives, Haiti, who lost her mother when the city was hit by the tropical storm Jeanne. © 2004 Dieter Telemans

MSF sends mental health teams to help people cope with the traumatic stress of natural disasters. Currently, teams are working with families that have been left homeless by the flooding in Gonaives, Haiti, and with the government workers who have buried the dead. In late 2003, MSF sent psychologists to Bam, Iran, following the severe earthquake there.

Care for the Neglected

MSF operates mental health programs not only in response to conflicts and natural disasters, but also for the most vulnerable groups in relatively stable societies. MSF has worked with institutionalized people, for example, in Armenia, Tajikistan, Albania, and in other, less-stable countries like Sierra Leone and Kashmir. In the town of Baoji, China, MSF offers psychosocial support to orphaned and abandoned children, many of whom have been abused.

"Eighty percent of the children have been mistreated or beaten–often by the 'adoptive' families who took them in–before being abandoned on the streets of Baoji," says Francoise Oppenot, an MSF volunteer and child psychiatrist who has treated children there. "They wander the streets, collecting empty bottles that they sell by weight, and have to beg to stay alive."

The goal of the program is to offer a stable environment for the children and the right conditions for their recovery, which includes temporary housing and access to medical and psychosocial care, as well as access to schooling.

The program has reached more than 300 children since 2001.