Information dated 14.10.2002 Mental health care crucial in emergency situations A recent article published on September 6, 2002 in the National Post (Canada) questioned the usefulness of trauma counseling. For Médecins Sans Frontières (MSF), psychosocial programmes are not only an essential response to human suffering but are part of an integrated approach for medical care. By Mira Dodig, Coordinator, MSF Canada MSF's experience over the last decade working in diverse settings such as Bosnia, Kashmir, Kosovo, Rwanda, Gaza/West Bank, Sierra Leone, and Sri Lanka has demonstrated clearly the benefit of these programmes for people who have directly experienced violence on a mass scale. Civilians are the main casualties of today's wars. Targeting civilians is a military tactic to destroy and undermine a society through psychological warfare. Most civilians caught in armed conflict witness events such as shootings, killings, rapes and loss of family members and possessions. Families are fragmented, communities decimated and natural support systems destroyed. For the individual, the experience of armed conflict often shatters their belief in security, the benevolence of other people and the future. The effects of such events can continue for years, decades, and even generations especially when the crisis is ongoing. MSF provides medical assistance to people caught in conflicts throughout the world. War is a dangerous, terrifying and degrading experience for most. Several surveys conducted by MSF illustrate the experience of war on civilians: in Sierra Leone we found that over eight in ten people surveyed were exposed to conflict including attacks on villages, exposure to crossfire and aerial bombardments; 41 percent witnessed the death of someone to whom they were close. Among inhabitants of a camp for people displaced by war in Sri Lanka, 18 percent of people surveyed had been arrested or kidnapped, and 11 percent tortured; 97 percent of people had lost their homes or property and 88 percent had a constant feeling of being unsafe. In Brazzaville, Congo-Brazzaville, 65 percent of people surveyed said they had been robbed, 57 percent were held against their will, and 48 percent reported the death of at least one family member. During a six-month period, two hospitals admitted 1600 women reporting they had been raped. MSF seeks to provide the most comprehensive medical care possible for it patients. In many places, psychosocial support is an important part of this care. Much of the mental stress experienced after traumatic experiences should be regarded as normal reactions to abnormal circumstances, and many people cope without professional support. For some, however, the psychological harm that results from armed conflict does not improve on its own. One common sign of psychological stress that MSF sees in its medical programmes is a high frequency of non-specific health complaints: painful conditions like joint and limb pain and headaches are common; some people develop gastric ulcers. Such conditions are often physical expressions of emotional pain that can be alleviated through psychosocial intervention. Other reactions observed include fears and phobias, aggression and other problematic behavior such as sexual violence and substance abuse, learning and language difficulties, and depressive moods. A few may later be affected by post-traumatic stress disorder or other psychiatric co-morbidity. MSF's psychosocial programmes aim to enhance resiliency for victims of conflict or natural disasters by encouraging the internal strength and external support networks that assist people's capacity to bounce back physically and mentally. We do this by employing local staff who work with the community itself, supporting existing physical, mental, social, spiritual and moral coping mechanisms and adapting programmes to meet the specific needs of the people affected. MSF runs various types of psychosocial programming around the world, including counseling and support programnmes for individuals, families and small groups, community outreach activities such as psycho-education and social events, and working with significant members of the community to strengthen local coping mechanisms. These programmes are an explicit acknowledgement of the injustice and suffering that people face in many parts of the world. In Colombia, where armed conflict has persisted since the early 1950s; we provide medical and psychosocial services to victims and families, many of who are living in isolated areas, often caught in the crossfire. In Hebron, MSF runs psychological support programmes for mothers and their children who suffer from psychosomatic disorders that hinder their ability to care for themselves. In Kashmir, there have been three wars between India and Pakistan since 1947 and armed conflicts have escalated throughout the past decade. Canadian psychologist, Reine Lebel, who began MSF's mental health programme in Kashmir, explains the situation: "These people have an army of one million surrounding them, while the Kashmiri population is only 6.5 million. The violence and cumulative stress is destructive, causing depression, anxiety, flaring emotions and violence in the home. Many have been tortured. Rape is common. Around 25 people die every day due to violence. There is a fear all the time from suicide bombers." In Kashmir MSF trains mental health counselors to provide psychosocial support (under clinical supervision) in the villages, and clinical support to the State Psychiatric Hospital, where over 200 patients are treated daily for traumatic-stress related problems and disorders like substance abuse, post-traumatic stress disorder, depression, and suicidal tendencies. MSF's experience over the last decade working in diverse settings such as Bosnia, Kashmir, Kosovo, Rwanda, Gaza/West Bank, Sierra Leone, and Sri Lanka has demonstrated clearly the benefit of these programmes for people who have directly experienced violence on a mass scale. On a very basic level, much of the value of psychosocial programmes comes from providing a safe environment where people can, if they choose; speak about their experiences and the violation of their human rights. These programmes provide a space where people are listened to and given support, and help people regain control over their lives. Such help is an integral part of the humanitarian response to suffering.