Treatment for sorrow

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Médecins Sans Frontières has been active in Palestine since 1993. We have worked with child victims of the first Intifada, Palestinian prisoners, malnourished infants and their mothers and, since September 2000, with children and families in the midst of the current Israeli-Palestinian conflict in Gaza and Hebron. Our program initially provided medical care but given the situation, soon expanded to include psychological services because "humanitarian aide does not address only physical needs. It must respond to humans in their complexity and, even, their very essence. Restoring people to a state in which they can exercise choice, freedom and the ability to act on the world is as essential as feeding them, keeping them warm and nursing them" (Martin, 1995, p. 18). This suggests that by connecting and coordinating with other aid efforts, psychiatric intervention assumes its rightful role in humanitarian response; its goal being: to care for human beings in their complexity. The four elements of a comprehensive mental health program are comforting, treating, witnessing and training. Mental health care providers must adopt new cultural perspectives Psychiatry today plays an increasingly important role in the field of humanitarian medicine, with growing numbers of psychologists and psychiatrists joining health care teams responding to humanitarian disasters. The major NGOs are instituting mental health programs and developing techniques for psychological care. Psychological trauma is not a new subject, but it takes on new dimensions in programs that assign health care providers - often young volunteers who want to work outside their own cultural settings - to conflict and catastrophe sites. These psychiatric humanitarian aid workers often say they are inadequately trained and prepared for such work. They want to be able to rely on well-defined concepts of humanitarian psychiatry, use specific techniques and evaluate results. They would also like to tailor their actions to the contexts in which they intervene. To be able to modify their approaches they must understand the individual and collective experience of the people for whom they will be caring. This suggests why humanitarian psychiatry falls under the rubric of transcultural psychiatry. Individuals targeted for mental health services are members of groups and cultures. They have their own knowledge base as well as their own social and cultural representations of health, illness, trauma and family. When we work outside our own culture we must be conscious of differences and familiar with others' collective responses. To provide humanitarian aid, participants must undergo a process of personal development and change. This extends well beyond the preparatory (and uneven) briefings that expatriates receive. They must develop their own approach to adapting to their new work setting and to cultural and current developments in the world that will be their temporary home. This involves, simultaneously, struggle and enrichment. Such a shift in perspective allows humanitarian mental health care providers to use their own emotions and internal conflicts as professional resources. Even as they struggle to hold onto their identity and knowledge base, humanitarian aid expatriates often face powerful forces pressing them to change their habits, ideas and beliefs. In that sense, voluntary expatriation can be seen as a form of human migration. Humanitarian aid workers intervening overseas must change their practices and beliefs even as they maintain their identity. In that sense, voluntary expatriation can be seen as a form of human migration.
Acknowledging emotional trauma and the role of the witness Since its founding, Médecins sans Frontières has sought legitimacy from international public opinion, not from national governments. This is where MSF breaks ranks with other international organizations like the Red Cross. Volunteers provide care and speak out about what they have seen. They are going towards medias to make the public aware of the suffering of the people they are caring for. But it quickly became clear that the act of speaking out had to be distinguished from some humanitarian media circus stripped of ethical foundation. Bearing witness means giving voice to the direct experience of the collective trauma of specific populations, like refugees or particular ethnic groups. It also means meeting people face-to-face. In such encounters, affected persons express their anguish; an anguish felt collectively as well as individually and within the family group. This testimony has a profound effect on those who listen to and absorb it. They are moved to respond on a medical and material level, as well as on an emotional level. One of the emotional responses is, clearly, the impulse to ease pain and restore the full humanity of people who have suffered violence's dehumanising effects and other painful experiences. This calls for consolation in the most active sense of the word. But although it may be a necessary action, it is not a sufficient response. Profound trauma and despair prevent many people from expressing themselves. Others - including children and babies - do not or can no longer speak. The process of speaking out and bearing witness requires that people be heard. It allows them to voice their despair and to imagine a kind of treatment that would meet not only their physical needs but restore their emotional capacity as well. That capacity is clearly affected by the crises they have experienced and continue to experience. Rather than seeking factual, "objective" accounts, our approach allows us to see events through the eyes of those who experienced and suffered from them.
Humanitarian aid settings are, first and foremost, emergency settings. Experience in managing emergencies (including natural catastrophes and war) has led humanitarian aid organizations to develop specific expertise (including ready-to-use kits, protocols and organizational structures) and has put certain professionals, including logisticians, resuscitation specialists, surgeons and emergency care nurses, on the front lines. But this is the first time we have practiced real emergency psychiatry; that is, intervening in the midst of traumatic events. Previously we intervened to ease events' after-effects. Now we are there with people as the trauma occurs and even growing in intensity. We provide psychological care to strengthen their defenses and allow them to hold on in spite of everything. We address the effects of trauma on infants, children, adolescents and their families. Many fields recognize the significance of this concept, which now extends well beyond the medical setting. As reflected in the term PTSD (Post-Traumatic Stress Disorders), the broader concept has contributed to a recognition of suffering that is not limited to the spontaneous empathy expressed in cases of war, conflict, persecution or catastrophe. Empathy, our capacity to put ourselves in another's place, is an instantaneous mental state. It is emotionally-based and situationally- dependent. Opinion is mobilized on the basis of empathy and of information presented visually or in writing. When attention wanes, that shift is not caused by moral weakness or laziness. Rather, empathy simply evaporates. Compassion is ephemeral. Humanitarian workers in the field may themselves sense empathy wax and wane. They may also feel its effects, which can both energize and paralyse. Naming and bearing witness is quite different. This process allows everyone - those who experience suffering and those who witness it - to identify and represent it in the psychological life of the individual and the group. We can point to five levels for specific intervention: accounts of traumatic events by those who have experienced them, individual traumatic experiences, collective and individual adaptive reactions and, lastly, the psychopathological level at which structural, lasting and often major disorders appear. Physiological complaints are more common than psychological ones.
Accounts of traumatic events This is the level of description provided by all who experienced traumatic events like those Gaza Strip residents have faced since the second Intifada began in September 2000. Descriptions of the events reveal people's fears and address the aggressive and dehumanizing nature of Israeli Army actions. These situations are obviously traumatic. Army actions include destroying property using bulldozers, occupying houses, threatening residents with tanks, rounding people up, patrolling at night and setting up checkpoints. Describing and documenting traumatic events, as well as distinguishing factual accounts from those distorted or exaggerated by fear, is a useful part of the evidencegathering process. It also allows the psychologist to accurately represent the experiences of people she or he is treating. "I often treat people who want to show me where an event occurred," one psychologist said. "I think going there permits expression and abreaction, an uncovering of the trauma. It often allows a person to return to a place where he or she has not dared to go for a long time." The media's approach to telling stories of traumatic events often overlaps with ours. There are, however, multiple versions of the same events. Our approach is a grassroots one. It allows us to see events through the eyes of those who experienced and suffered from them, as opposed to seeking a factual, "objective" account. Sharing tragic moments by listening to people recount them may be the only way to provide care, but it is significant. "We try to support the residents but really all we can do is be there," a psychologist in Gaza said in December 2000. "Our words seem pathetic. They always say they were waiting for us. They talk about us with their neighbors and ask each other when we will be there." Click on image for large size
Individual traumatic experiences This is the level of personal description provided by an individual who has experienced one or more traumatic events. Gaining a complete grasp of the experience requires going beyond clichés. Little by little, the person will open up and in the telling, begin to construct a specific and personal meaning of events. The experience is not solely negative but encompasses a broader, holistic awareness. Recounting the event in a therapeutic setting may help to prevent the onset of future psychological disorders. People have a tremendous need to tell their stories of trauma and few have political goals for doing so. Rather by putting words to disturbing and disorganizing experiences, they seek reassurance and to restore their humanity. They want to communicate with someone who is close enough to understand what they have been through, yet removed enough so that they are not just repeating their story ad nauseum. People will often talk repeatedly among themselves about events, though the consequences may be negative as much as positive. Talking to a "health worker," in the broadest sense of the term, initiates a therapeutic interaction that can transform the traumatic experience, allowing the individual to move beyond it rather than remain imprisoned by it. Collective adaptive reactions A common example is the behavior of people who remain in their homes even when, for example, the building is the target of bullet or rocket fire or regularly attacked by groups of soldiers and even, in extreme cases, when soldiers have occupied the roof. Residents know their houses will be requisitioned or destroyed if they leave so they stay on, living in fear. Even if resistance is an individual action, in which an individual assumes all personal and familial risk, the act is a collective adaptive reaction. Not all adaptive reactions involve that level of heroism. Others include regular, ongoing conversations about the current or prior days' events. When a single family member is designated as the one who is suffering and whose responses are judged abnormal, such behavior protects other family members from their own tendency to react in inadaptive ways. On a collective level, we observe reactions of fear, despair and revolt as well as rumors and acts of solidarity. It is important to monitor all these emotional shifts and symbols (for example, martyrs and olive trees in Gaza) because they change quickly and serve as indicators of the population's overall condition. Click on image for large size
Individual adaptive reactions The reactions observed are the emotions visible in the face of danger and violence, including the experience of intense fear and its physical signs, including trembling, unsteadiness, involuntary urination, nervousness and, sometimes, fainting. We next observe reactions that represent an effort to master fear: denial, losing oneself in daily tasks, participating in the confrontations. In many cases people are virtually trapped and cannot remove themselves from the situation. Take the example of houses caught under nighttime attack, with the incessant, frightening noise of tanks rumbling by and children crying and clinging. What are people to do? What is the appropriate adaptive behavior? In such situations, individuals internalise their emotions in the form of future disorders that may manifest physiologically, psychologically or behaviorally. Prevalent wartime emotions also include rage and impotent anger. But whatever the "quality" of emotions revealed at the time, the challenge is reining in the "quantity" of emotions. If emotions can be mastered and controlled early on, they may not emerge later as a disruptive, disorganizing flood. Pathology with known disorders Acute states can be distinguished from anxious states, which are more common particularly among children. They may develop an excessive attachment to the mother or an older sibling, refuse to leave the house or even a particular room or develop sleep disorders and awaken screaming from nightmares. They can sleep only when close to the mother. Sometimes these children develop a state of permanent, invasive fear with startle and hypervigilance responses. Among adults, painful conditions like joint and limb pain and headaches are common. Some may develop genuine psychosomatic pathologies like gastric ulcers. True psychotic decompensation may be observed, in which the person shows transitory signs of insanity, thereby escaping an intolerable reality. Post-traumatic stress disorders appear later, affecting sleep and all major activities, including eating, learning and daily living tasks. The war context may revive prior states of psychological decompensation. The most vulnerable individuals are at greatest risk in such situations. Earlier emotional problems may, themselves, have resulted from prior trauma. In extreme situations or immediately following them, physiological complaints are often more common than psychological ones. This is particularly common in cultures that do not distinguish between physical and emotional illnesses or, in the simplest terms, suffering. Sleep disorders are often observed and are among the range of affected physical functions including eating, sleeping, breathing, elimination and sexuality. Overwhelming fatigue is common. Physical functions are disorganized and children, in particular, manifest partial transitory regression. For example, children who live with fear on a daily basis can experience enuresis. Often people consume large amounts of food or conversely, may be unable to eat, complaining of problems swallowing. They may present with weight loss problems. (A common joke among MSF's female team members in Hebron, both expatriates and Palestinians, was that "fear and danger have a silver lining - they keep you slim!") If the mother-child relationship is disrupted, especially if the mother experiences post-traumatic problems, children may be particularly affected. Traumatic losses and bereavements may also generate medium-term psychological consequences. Depression may have long-term consequences for child development and the parent-child bond. As events recede in time, a variety of symptoms may appear: fears and phobias; behavioral problems and disorders; aggressivity and violence; learning disorders, language disorders; mother-infant relationship disorders; avoidance behaviors; blunted affect, inhibition, passivity and depressive states. The relationship of events to the initial trauma is obvious. The list can be expanded to include the bitterness that feeds hatred and is passed on from one generation to the next. Deeper understanding improves treatment and care. We must be willing to name the horror and speak the unspeakable if we are to keep hope alive and hold onto the dreams necessary to work in these extreme circumstances. We must do this to break the cycle and prevent trauma from recurring in successive generations. We must heal human suffering, even when it is unspoken and its wounds invisible. We must, therefore, begin by speaking of it. Christian Lachal and Marie-Rose Moro are child and adolescent psychiatrists. Marie-Rose Moro is an ethnopsychiatrist, psychiatrist, and psychoanalyst, and director of the Child and Adolescent Psychopathology Department of the Avicenne de Bobigny Hospital, where she established a crosscultural practice. She is director of the review L'Autre and organizes MSF's mental health missions. Bibliography: Moro M. R. et Lebovici S. (Eds), Psychiatrie humanitaire en ex-Yougoslavie et en Arménie: face au traumatisme, PUF, 1995. Martin D., "Psychiatrie et catastrophes. Le point de vue d'un humanitaire," pp. 17-22, in Psychiatrie humanitaire en ex-Yougoslavie et en Arménie: face au traumatisme. Lachal C., "Des adolescents en guerre", in L'Autre, cliniques, cultures et sociétés, pp. 67-86, vol. 2, n° 1; Paris, éditions La Pensée sauvage, 2001. Palestine-Israel Journal of Politics, Economics and Culture, n° 4, Jerusalem, autumn 1994.