Pakistan: “The time people are allowed to grieve in Pakistan is often too short”

Interview with Saràh Dina, mental health officer in Pakistan

“A lot of people are surprised that talking and counselling can help. It is a very medication dependent society. When someone has a problem they tend to just take a pill”, says the Australian psychologist Saràh Dina. After nine months in Pakistan, she leaves the country encouraged by the positive results that mental health sessions have had among a population affected by conflict, poverty and challenging ways of life. During her time in Pakistan, Dina coordinated the work of a team of Médecins Sans Frontières (MSF) counsellors in the province of Baluchistan. She explains what she learnt as a result of the experience.

Why do we have a mental health programme in Baluchistan province?

Our mental health programme in Baluchistan benefits the patients from projects that MSF runs in the provincial capital, Quetta and in the adjacent town of Kuchlak. We started the programme in 2008. A doctor who was working in Kuchlak at the time noticed that many women came to the clinic with physical complaints, general body pain and headaches that couldn’t be explained medically. When they looked into it in more depth it was clear that there were psychological reasons for their pain. The programme was extended to Quetta paediatric hospital a couple of years ago.

What kinds of people request our services?

Most of our patients are female (around 82 percent) and are predominantly adults, but we also see children and this part of our programme is growing. The majority of our beneficiaries come from low socioeconomic backgrounds. Many come from Afghanistan originally; they arrived as refugees years ago. We see a lot of women with general depression and anxiety. On the surface, it can seem like any other place in the world but when you dig a bit deeper you find that the reasons for these problems are very specific to the region.

What are the most recurrent factors affecting mental health?

We see many poverty and violence related issues. Normally people come to us with a combination of different factors affecting their psychological wellbeing. Some people have been exposed to war and conflict. Many have experienced a lot of grief and loss, also in relation to situations like maternal and child deaths. Having said this, it is a very resilient community.

Could you describe some typical cases?

It is difficult to describe a typical case, but as an example we have had women come to see us who lost their husbands many years ago during the war, and yet they still retain a glimmer of hope that they may still be alive. This can haunt some women for the rest of their lives. They are now required to be financially responsible for their children if they have no other family around to help, and this puts a lot of pressure on them.

Some women are also faced with violence in the family home, and come to see the counselors to seek relief from it all, not being able to talk about this in such a frank and open way elsewhere. We also have men and women who come to us with symptoms of post-traumatic stress disorder. Some have nightmares and flashbacks to periods in their lives that they would rather forget – from war and conflict, to violence at home.

How do these women cope with their grief?

The time people are allowed to grieve is often very short. Some women in their late 30s or early 40s have already had more than 10 children, some as many as 15 or 16, and not all have survived. We see cases of women for example who have lost four or five children, yet the expectation is that they just move on after each death. It is, however, important to stress that this is not the case for all families.

What feedback do we get from our patients?

A lot of people are actually surprised that talking and counselling can help. It is a very medication dependent society. When someone has a problem they tend to just take a pill. Many people have been taking psychiatric medication for many years and when they come to us they say that the medication did not help them. This is likely due to an over-prescription of unsuitable medication and a misdiagnosis. At the beginning we were not sure how this programme would work because the concept of counselling and mental health is very new in Baluchistan but over the years we have seen a very positive increase in people accessing our services. On average, our counsellors are seeing five patients per day, which is a lot as you spend a considerable amount of time with each patient, and patients come to see us three or four times. Some people stop after these sessions because they feel better, others need to come back. We are not equipped to deal with acute psychiatric problems, such as psychosis. These patients have to be referred to specialised centres. We could see patients for many years, but it is not our aim either to provide long term counselling.

Could you share a positive experience with us?

Given the uncertainty of the context where I was working, I was never sure if I would be able to have a follow-up appointment with a patient. The team of counsellors would inform me of any progress with any particular women I had met. One woman came to see one of the counsellors and knew I was nearing the end of my stay. Not knowing if we would meet again she asked the counsellor to teach her a few words of English. She then thanked me in broken English over the phone for our work. I realised that you can communicate with people with depth and kindness, without speaking the same language.

MSF offers mental health counselling sessions in two different locations in Baluchistan province: in the provincial capital, Quetta, and in Kuchlak, which is an adjoining area. In Kuchlak, MSF runs a clinic for maternal and child healthcare and a programme for leishmaniasis. In Quetta, MSF runs a paediatric hospital mostly treating neonates and also offers nutrition services. Between January and July 2014, MSF did 3,176 mental health consultations. The target of consultations for the whole year was around 4,000 but this goal has been increased given the positive trend.