Nurse Maria Meo was with the first team from MSF to land on Aceh's shores. She recalls those first few days, when the trauma resulting from the tsunami became increasingly apparent.
"There was one village I will never forget. We were the first aid workers to arrive and people had been eating leaves to survive. While the doctors and nurses treated the wounded and identified patients requiring evacuation to the hospital in Banda Aceh, I tried to calm the villagers by explaining what had happened - a very basic but very necessary first step. "These people had been cut off from all communication and had no idea of the extent of the devastation caused by the tsunami. As far as they knew they were the only people affected. "And then I just listened. People were so desperate to tell their story they were literally shouting over each other."
"We were treating hundreds of patients in our mobile clinics every day and as you attended their wounds they would invariably break down and cry. We were also overwhelmed by the sheer number of patients coming forward with psychosomatic complaints. Other people were just wandering the streets in a state of distress. We desperately needed psychologists to refer these patients to."
Fortunately MSF had previously run mental health programmes in Indonesia and had experienced national psychologists who could immediately get to work.
The type of support MSF mental health programmes offered in the first few weeks was extremely practical. After a natural disaster on the scale of the tsunami people frequently go into shock. Some become unable to function and lose the survival instinct to find food and shelter.
In Aceh, MSF teams sought to identify the most vulnerable and ensure their basic needs were being met. Psychologists were also attached to mobile clinics and health posts to ease pressure on medical staff, and information was disseminated amongst health staff, community leaders, religious heads and the general public about the causes of the tsunami and the psychological impact it might have.
Indonesian psychologist Yenni Fabrina arrived in Aceh on New Year's Eve, just four days after the tsunami.
"When we first arrived in Aceh, it was chaos. I was quickly attached to a mobile clinic and traveled with them by helicopter as they conducted assessments and distributed aid along the west coast. We found people in a state of shock.
"There was one village I will never forget. We were the first aid workers to arrive and people had been eating leaves to survive. While the doctors and nurses treated the wounded and identified patients requiring evacuation to the hospital in Banda Aceh, I tried to calm the villagers by explaining what had happened - a very basic but very necessary first step.
"These people had been cut off from all communication and had no idea of the extent of the devastation caused by the tsunami. As far as they knew they were the only people affected.
"And then I just listened. People were so desperate to tell their story they were literally shouting over each other."
As the weeks passed and the situation in Aceh stabilised, MSF mental health programmes began to work more independently. Teams moved out from the capital and set up programmes in hard-hit areas along east and west coasts. They offered psychological care to those living in tents and temporary shelters known as barracks, trained health staff, teachers and community leaders and placed psychologists in health clinics for referral. Eventually, they even built their own counselling centres.
Now, 11 months later, MSF has refined its programmes to better suit the needs of each location. It has maintained a practical, problem-solving approach.
"The psychological support we offer is very functional," explains MSF Mental Health Advisor Kaz de Jong. "We do not claim to cure people of all mental suffering. Instead we strive to find ways to reduce and manage complaints so that people can continue to care for themselves and their families. We can't make the pain go away but we can help people find ways to live with it."
In Aceh, MSF has used a combination of psycho-education, psychosocial activities, group discussions and counselling (both individual and group) to reach out to those in need. MSF mental health translator Dewi Agreni remembers how counselling helped one woman she stumbled across in the barracks.
"This woman would not stop crying. She couldn't sleep, she couldn't eat. Her daughter had been killed in the tsunami but as she never found the body, she could never accept the death. She simply refused to believe that her daughter was dead. We encouraged this woman to come for individual counselling. We worked with her to find ways to come to terms with her loss and after several sessions with a psychologist she was able to control her tears. She now also recognizes that her daughter is gone. She still feels pain, but at least now she is laughing again and able to hold down a job. It's amazing to see the difference."
Despite such successes, introducing mental health programmes to Aceh has had its challenges. Whilst MSF can ensure that those it treats get the best quality of care, the lack of any mental health structure in Aceh has meant that most people's psychological needs go ignored. There is no referral system, no training of health staff and few local psychologists to call upon. Other aid organisations have established programmes, but experience of mental health in such contexts and the use of qualified psychologists is limited.
30 years of vicious war in Aceh's heartland has also had its affects on the psychological well-being of its people. Although the conflict ended in August this year, many are still traumatized by their experiences and could benefit from having access to psychological support. The concentration of mental health programmes in the regional capital and their tsunami-focus means that in some areas, particularly those in-land, only a fraction of people in need are being reached.
Even in our coastal programmes, MSF psychologists are seeing more and more people who relate their problems to the years of violence, rather than just the tsunami. MSF is adjusting its programmes to be more tuned to the sensitive issue of conflict and is taking its mental health work into in-land areas.
The absence of any significant understanding of mental health amongst Acehnese people themselves - particularly the difference between psychological and psychiatric complaints - is another challenge MSF must face. This makes some individuals reluctant to come forward, and others harbour unrealistic expectations.
As MSF translator Dewi Agreno explains, "People in Aceh think that if you say someone is stressed, it means they are crazy, and the solution is to lock them up or medicate them. There is no concept of mental health here. Then, when they learn a bit more, they think that counselling is like medicine, a miracle cure that will fix all their problems overnight. It takes a lot of work to help people understand."
But perhaps the greatest challenge of all is in determining just how effective and appropriate our programmes are. Are we communicating with people in a language and with concepts they understand? Are our programmes culturally sensitive? Are we making the most use of natural coping mechanisms? And most importantly of all, do our patients feel we are really helping them?
THE "HAPPY" SCALE ... and other measurement tools
The so-called 'Happy Scale' was developed in order to provide a swift, rudimentary, on-going evaluation of the effectiveness of MSF mental health programmes.
At the beginning of each counselling session, patients are asked to rate their feelings and ability to function on a scale between 1 and 10. They are asked the same questions during follow up sessions and the results are compared for possible improvement.
It is a simple measurement but one that puts a concrete figure on an abstract concept. It also allows the counsellor and the patient to reflect on the progress they have made.
An earlier, random, survey in Aceh asking MSF mental health patients to value the benefit of our programmes on a scale of 0-6 gave MSF an average rating of 5.6
Other measurement tools designed to gather objective data on mental and psychosocial needs exist and often rely on questionnaires. However, such questionnaire tools must be used with caution.
Defining the experience of living through a massive crisis through a simple checklist has its limitations. Also, such tools are frequently not adapted to the culture where they are applied and consequently fail to take account of natural coping mechanisms, levels of resilience and subjective perceptions of experiences.
Making tools culturally specific - or 'validation' as the process is termed - is possible but takes considerable time and resources, the benefit of which must be weighed against the need for immediate action.
These are questions MSF faces everywhere it works in the world, and over the years various tools have been developed to address them. In a number of projects in Aceh, MSF has recently introduced a measurement scale commonly referred to at field level as the 'happy scale'. Although still very much in its introductory stage, results so far indicate that our programmes in Aceh improve patients' sense of well-being and ability to cope. Research is also underway to examine the relationship between mental health and culture in Aceh, and evaluate the cultural appropriateness of MSF projects. The results are expected to be ready early next year.
MSF's activities in Aceh have demonstrated the important role psychological support plays in any emergency response to natural disasters resulting in massive loss of life and livelihood. From this experience MSF has improved its ability to effectively incorporate psychologists into its activities from the outset.
The challenges faced and the sheer number of MSF mental health programmes in Aceh have also allowed MSF to explore in greater depth the importance of context and culture on a community's ability to address and overcome trauma, and if and how MSF needs to take account of this when implementing its programmes.
"Our work in Aceh has taught us much about how to adapt programmes to ensure they are culturally relevant," concludes Mental Health Advisor Kaz de Jong. "The constant challenge now is to find a balance between learning and doing, so that we maintain the ability to respond effectively and with speed to mental health needs and continue to improve our practice in Aceh and elsewhere.
MSF MENTAL HEALTH ACTIVITIES
In Aceh, MSF has used a combination of psycho-education, psychosocial activities and counselling (both individual and group) to reach out to those in need:
Psycho-education involves introducing both key players and the public to the concept of mental health. People are encouraged to recognise common complaints amongst themselves and their friends and family, and are taught basic techniques such as relaxation and breathing to cope with them. Practical information about the tsunami and its causes is also distributed.
Pscyhosocial activities range from cooking and henna tattooing to building recreational facilities. The informal, communal environment offers the opportunity for discussion, for psychologists to be able to identify those with mental health complaints, and also helps reform community ties by bringing people together.
Group discussions provide another opportunity to explore issues of concern to people and how they are coping with them.
Group and individual counselling is for those with identified mental health complaints and involves extensive dialogue with a psychologist. The most common mental health complaints MSF programmes see in Aceh are sleep disorders, nightmares and flashbacks, intense feelings of sadness and hopelessness, and psychosomatic complaints. Sometimes these are so overwhelming that those suffering from them feel unable to cope with day-to-day life. In counselling sessions MSF psychologists seek to reduce these complaints and reinforce natural coping mechanisms.