Mental Healthcare in Kashmir, DRC, and Iraq

Patients at MSF health post in Bowen, Kupwara where basic health care and mental health counselling is provided to the local population, Kupwara, Kashmir, India on April 07, 2010

INDIA 2010 © Giulio Di Sturco

Snapshots from MSF mental health programs in Kashmir, Democratic Republic of Congo, and Iraq show some of the complex issues confronted by those who seek counseling.  

Doctors Without Borders/Médecins Sans Frontières (MSF) provides emergency medical aid in catastrophes all over the world—during armed conflicts, for example, or after natural disasters, or in the midst of famines and epidemics. MSF doctors and nurses are often seen bandaging the war-wounded, rehydrating a cholera patient, performing an emergency cesarean section, or treating some other physical ailment. But for more than 20 years, MSF has also been caring for patients’ mental health.

For people who have lived through terrible events, the psychological consequences can be severe. Depression and anxiety can immobilize them, often just when they need to take action for themselves and their families.

MSF’s mental healthcare aims primarily to reduce people’s symptoms and improve their ability to function. Often this work is done by local counselors specially trained by MSF. MSF psychologists or psychiatrists provide technical support and clinical supervision. When appropriate, MSF’s counseling services may reinforce or complement mental healthcare approaches that already exist in the local community. And specialized clinicians can treat severe mental illness, in the event that cases arise.

The severe cases are rarer, but overall, the needs are high. MSF, therefore, has continued to expand its mental health programs. In 2009, MSF’s mental health teams around the world performed more than 100,000 consultations.

People sought help for many reasons—the agonizing loss of a child in an earthquake, the trauma of sexual violence, the anxiety resulting from being in or near a violent conflict. MSF mental health workers listened to their stories and helped them find ways to cope and move on with their lives. 

What follows is a series of snapshots from MSF mental health programs. They are taken from Kashmir, Democratic Republic of Congo, and Iraq, and they illustrate some of the complex and painful issues confronted by those who seek counseling, as well as some of the challenges encountered by MSF in providing these services.   

Kashmir: People Traumatized By Decades Of Violence

MSF counselor Madina Bukhari works in Kupwara district, where for years the population suffered the consequences of the ongoing Kashmir conflict. Most of the people she counsels are direct victims of this violence who now suffer from depression, anxiety, and post-traumatic stress.

“I’ve had women telling me how they were having dinner with their families when someone burst in and shot their husband in front of their eyes,” she recalls. “Others have lost family members or witnessed violence. Some of the youth were tortured. All these memories are often very vivid in their minds.”

Madina finds it rewarding to aid in the recovery of fellow Kashmiris. Many of the people she counsels report feeling better afterwards. “Counseling helps them live in the present and shows them how the present can be better than the past,” she asserts. “We encourage them to take part in their community’s activities, which can help get them back on track and get on with their lives.”

MSF’s mental health program in Kashmir carried out more than 5,800 consultations in 2009. One patient, a man named Gulam, suffered from depression for years before being referred to MSF. He endured headaches, sleep disturbances, and memory loss, and was lonely, withdrawn, and unable to work. Counseling helped him get his life back on track.   

“Since I’ve seen a counselor, I’ve made so much progress,” he says. “I started by writing about my emotions regularly and it helped to be able to express them. Now I’m reading and writing a lot, I can concentrate very well and I’d like to continue studying and improve my education. I know I can do it now.”

“I’ve had women telling me how they were having dinner with their families when someone burst in and shot their husband in front of their eyes”

-Madina Bukhari, MSF counselor in Kupwara district

Democratic Republic of Congo (DRC): Talking About Trauma

The people of eastern DRC have suffered through decades of brutal and traumatic armed conflict. Hundreds of thousands have been displaced by fighting. Many have been stripped of their homes, possessions and livelihoods, while others have been killed, wounded, or raped.

Since mid-2009, psychosocial counseling has been part of the range of health services offered by MSF in the towns of Kitchanga and Mweso, in DRC’s North Kivu province. Counselors recruited from the local population—and often victims of the conflict themselves—meet with a steady stream of people wanting to talk about the trauma they have endured. More than 1,000 people started counseling in the first six months after the program opened.

Many who come for counseling are women who have suffered physical or sexual violence. A woman from Kitchanga, 54, recounted what happened to her before she came to see MSF: “I was out with a group looking for food when we heard gunshots coming from all sides. We ran, and dispersed into the woods. I was with two young people and they were killed right there in front of me.

“I fell to the ground, and when they caught me, they raped me. When they had finished, one of them made to shoot me, but the others stopped him, and cut me with knives instead.

“When armed groups started coming to our village, we would spend the night in the bush. If you had nothing to give to the bandits, you’d be killed. Every day, people would talk about someone they knew being beaten or stabbed to death.

“The bandits said that the forest belonged to them, not us. They told us that the night belonged to them, too. So we gathered all our possessions and came here to the camp. Since then, I’ve been living here in the camp. My heart is always beating too fast. I’m terrified whenever I go to collect food—how could they do this to me?

“I spend sleepless nights and then I’m tired in the mornings. I think about many things. I think about the people I’ve lost and those who are still around. I think about my children who have died. I think about my child, who is still missing, and I don’t know whether he’s alive or dead.”

Iraq: Overcoming Security Challenges To Address Mental Health Needs

Overall levels of violence may have decreased in Iraq, but several areas remain highly volatile, and many people continue to die in bombings and assassinations. This unpredictable violence—past, present, and future—is the leading cause of trauma-related symptoms and psychological distress among Iraqis.

MSF teams determined that there were few counseling services available in areas of central and southern Iraq that had been hard hit by violence. But providing this care is complicated by the lack of security, which forces MSF to manage its Iraq programs from neighboring Jordan, and by a cultural aversion to mental health care evident in much of the population.

In collaboration with the Iraqi Ministry of Health, MSF mental health officers trained 17 counselors to work at three hospitals in central Iraq, beginning in September 2009. By August 2010, the counselors had conducted more than 2,500 sessions. Sessions focus on everything from daily stressors—like inability to pay for school fees—to trauma directly connected to the violence.   

MSF’s international teams visit the counseling programs in Iraq once a month. The rest of the time, the team relies on technology to connect the Iraqi counselors with MSF mental health officers in Amman. In 2010, the team began using a videoconferencing system that has greatly improved supervision and collaboration.

“Using the videoconference, I am more connected to the counselors,” says one of the MSF mental health officers. “I feel more in touch with the person. I am also able to get more ideas about the attitudes and skills of the counselor... I am able to have an emotional impact.”

The team plans to expand the reach of the program by working with local communities to increase awareness of mental healthcare and to reduce the stigma associated with it.