The effects of fear: MSF's mental health program in Ingushetia and Chechnya

"Every family and person has a life story that is closely connected with war; maybe they didn't see someone die in front of them, or witness a bomb explode, but war influences their lives at every turn."

MSF has run a mental health programme in the North Caucasus, for these internally displaced people (IDPs) since 2002. The program operates in Ingushetia and also within Chechnya itself - where estimates suggest over 100,000 people remain displaced.

Many of IDPs in Ingushetia are housed in spontaneous settlements, or kompaktniki. Often sub-divided warehouse spaces, former factories or roughly fabricated plywood containers, the kompaktniki are in a pitiful condition. Inhabitants are crammed into box-like rooms - a family of six or seven will often share a space four metres square.

Cooking is done on small gas rings, the frail flames are often left burning so as to provide heat. Some families have lived like this for over five years. Most of the young children playing among the dilapidated dwellings and pieces of rusting, old machinery have known no other life.

Anxiety, depression, anger and suicidal feelings are common. People talk of lives dominated by fear: those living in spontaneous settlements in Ingushetia are subjected to regular military and police raids, or zachistki.

As Marieta Gudieva, the MSF mental health program manager in Ingushetia explains, "zachistki breed a perpetual feeling of insecurity. Young men are often the targets, but it is very stressful for the whole community, and those who are taken away by the security forces often do not come back.

"And I know many women who are reluctant to go back to Chechnya because they fear the situation there is even worse for their sons."

This unpredictable existence stunts the displaced population's ability to think of the future.

"Not only have people changed their physical location, but their sense of themselves and their place in the world is also turned upside down," said Marieta. "Their sense of the future, their ability to plan and hope - all are altered. Very often they lose the ability or desire to talk about the far future, and instead focus on the practical, pressing realities of daily life and survival. They become numbed to death and kidnap - events that before the war would have been a shock to the community are now part of life."

In Ingushetia, the programme focuses on the spontaneous settlements (kompaktniki) where many of the most vulnerable Chechens live. Eight mental health counsellors visit 27 settlements (in the Sunzhenski district, bordering Chechnya, and around the republic's largest city, Nazran); conducting individual and group sessions; educating people on how to recognise and cope with different types of psychological problems; and facilitating contacts with other organisations who can offer the vulnerable aid.

The counsellors rely on a network of volunteers who, as people who live in the settlements themselves, help to identify people who need help, and also organise community and social activities, like football, dancing or craft workshops. Counsellors also have a room in the MSF medical centre, which provides general medical, paediatric and gynaecological services in an area of Nazran where many IDPs are living.

© Simon Norfolk (2003)
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"People are ashamed," said Marieta. "Our Chechen mentality is that if you go to a counsellor you are showing weakness. So we see lots of psycho-somatic presentation, when psychological problems manifest themselves physically."

 

In Chechnya, counsellors are attached to mobile teams, working in temporary accommodation centres and villages in the Grozny region, but also provide 24 hours support to the emergency trauma hospital in the capital, Grozny. Psycho-social counselling is also an integral part of the TB program that MSF runs in four districts in Chechnya.

An MSF survey in 2005 showed that 77% of the inhabitants of temporary accommodation centres in Grozny never, or only occasionally, felt safe.

As in many places in the world, in Chechen culture the stigma attached to seeking help is fierce, especially for men.

"People are ashamed," said Marieta. "Our Chechen mentality is that if you go to a counsellor you are showing weakness. So we see lots of psycho-somatic presentation, when psychological problems manifest themselves physically."

Counselling, psychology and the idea of 'talking cures' have only developed in the Russian Federation since the collapse of the Soviet Union. The population is more familiar with the more medicalised specialism of psychiatry, which tries to manage severe mental illness with drug therapy.

The MSF team believe much can be done to assist the population to cope with the psychological trauma without resorting to medication, but they have links to psychiatrists to whom they can refer severely ill patients.

"The links we have are good," says Lamara Umarova, the MSF psychologist responsible for the two programs in the Caucasus. "And the psychiatrists also refer to us. In fact, in one hospital - Achoy-Martan - when MSF phased out its presence, the staff convinced the administration to hire a psychologist, as they'd seen the benefits from our program."

Medical staff themselves are often among MSF's beneficiaries, especially in Chechnya, where the counselling team offers a 24 hour service in Hospital Number 9 - the republic's main trauma centre.

As Lamara says, "Every family and person has a life story that is closely connected with war; maybe they didn't see someone die in front of them, or witness a bomb explode, but war influences their lives at every turn." This is true of the counsellors themselves, many of whom have lost relatives and homes in the 11-year conflict. Regular clinical supervision and training helps them keep their skills up to date and aims to prevent burn-out.

Sustained improvement in the psychological health of the population remains hard to achieve while the situation remains insecure. Marieta feels that, "at the moment people are trying to survive. The real consequences of war will be evident when people once more begin to live normal lives - the lives they are living now are not normal."

But the attitude to psychological support and asking for help is at least changing slowly.

"The other day, a woman came to see one of our counsellors out of the blue," relates Marieta. "She said that she was worried about herself. She had begun to shout constantly at her children, and to nag her husband incessantly. She said that she knew she needed help."