Mental HealthReforms Special issue: > Mental Health and Development Aid
A Global Initiative on Psychiatry publication
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09 No. 1
Contents
Editor Ellen Mercer
Foreword
Editorial Board Katja Assoian Elena Mozhaeva Robert van Voren
Mental Health and Development Assistance
Graphic Design www.bade.nl
Mental Health Nursing in Low- and Middle-Income Countries
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By Robert van Voren
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By Florence Baingana
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By Rob Keukens Printing Klomp grafische communicatie Mental Health Reforms is a publication of Global Initiative on Psychiatry (GIP). While MHR is distributed free of charge, we are dependent on your support to sustain the journal. Contributions are therefore welcome and may be made to: ABN AMRO Bank ’s Gravelandseweg Branch Hilversum, The Netherlands BIC: ABNANL2A Euro account:62.07.29.074 IBAN: NL16 ABNA 0620 7290 74 USD account: 62.07.29.244 IBAN: NL82 ABNA 0620 7292 44 To request additional copies please contact: Global Initiative on Psychiatry P.O. Box 1282 1200 BG Hilversum The Netherlands Tel.: +31 35 683 8727 Fax: +31 35 683 3646 e-mail:
[email protected] www.gip-global.org
Addressing the Gaps in Addiction Treatment and Community Mental Health in Kisumu, Kenya - SINAM’s Western Kenya Initiative
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By Antony Otieno Ong’ayo
The Mental Health and Poverty Project: Some Preliminary Findings
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By Alan J. Flisher, Crick Lund, and the MHaPP Research Program Consortium
GIP in Tajikistan: Working Towards Well-Being in all its Facets
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By Ella Terburg
Psycho-social Work with Internally Displaced People in Georgia: Problems and Solutions
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By Jana Javakhishvili and Nino Makhashvili
Hope Abandoned
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By Robert van Voren
Mental Health Challenges for Refugees and Displaced Persons
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By Ellen Mercer
Improving Living Conditions & Promoting Reintegration of Mulleriyawa Psychiatric Hospital Patients
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By Jayan Mendis
Mental HealthReforms Special issue: > Mental Health and Development Aid
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09
Mental Health and AIDS as an Important Development Priority
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By Melvyn Freeman
No. 1
A Call to Action: Including Mental Health on the Development Agenda
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By Benedetto Saraceno
Russian Summaries By Elena Mozhaeva
A Global Initiative on Psychiatry publication
Cover photo: Tea break during the work in the occupational therapy project, Tajikistan
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March 2008 The opinions expressed in this publication are the sole responsibility of Global Initiative on Psychiatry or guest authors. Articles may be reprinted only with the prior approval of the author(s).
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Foreword
Dear Readers, In recent times, the world community has been in shock. What started as a banking crisis quickly developed into an economic recession of massive proportions. The end of the tunnel is nowhere in sight and the consequences are difficult to determine at this stage when the world economy seems to be a rollercoaster out of control. Persons with mental health care problems in the developing world have always been in an allconsuming crisis. The world is experiencing a new financial crisis but, for these individuals, it is and has been a fact of life every day. They have had to learn to cope with the devastating effects of mental illness, and also live with the stigma and exclusion the illness entails and the absence of services to support them in their ordeal. Mental health has never been an attractive subject for donors, whether governmental or private. For most foundations and grant making organizations, mental health is not included in their target issues, often because it is not considered to be a compelling subject that enhances visibility or standing. Pharmaceutical company support is, at times, problematic even though psychiatry is one of its markets. Governments usually do not incorporate mental health as a priority, and, thus, any program they have in the field of development aid does not include mental health as a key issue. Development aid has become an integral part of the budgets of most developed nations; however, mental health has not been included in any of the development aid programs, primarily because it is not mentioned in the Millennium Development Goals. When mental health is included, it usually relates to trauma care which is, unfortunately, rarely linked to the development of a sustainable mental health care system. As a result, when foreign aid organizations move away, much of what has been built up crumbles and eventually disappears. Many organizations dealing with trauma, or PTSD, refuse to consider their programs to be “mental health related,” or “mental health oriented,” fearing that doing so would cause them to lose necessary financial support from reluctant donors. Organizations dealing with the effects of torture often refer to their work as being “human rights work,” also refusing to call it “mental health” for exactly the same reason. “Call it what you want, but don’t call it mental health!” At the same time, the mental health community hardly ever challenges the development aid world; they prefer to avoid the unpleasant task of lobbying donor organizations and trying to convince them to mend their ways, and to start considering mental health as a priority. Sometimes their argument is that mental health can only be developed in a sustainable fashion when the government agrees to provide the necessary finances, yet they tend to forget that convincing authorities to do so can take years, many years, and that lobbying them can be a costly affair. It is clear that in time of a global economic crisis, persons with mental illness will suffer again; possibly even more than others. Donors with decreasing assets must cut back on their spending; governments must reconsider budgets, often pushing mental health further to the end of the line. The upsurge that is so much needed, the extra and prolonged investments that are crucial in helping develop mental health care services where there are none - that will undoubtedly be postponed indefinitely. It is another missed opportunity. Robert van Voren is the Chief Executive Officer of GIP
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Mental Health and Development Assistance Development assistance is an important major component of health financing for low income countries, and, therefore, has the potential to influence what the priorities will be in those countries. However, development partners cannot fund areas that are not identified as priorities in the client countries; so ultimately, it is countries that determine what will or will not be financed. In discussing mental health and development assistance, it is therefore important to keep in mind that some of the development assistance decisions are based on the priorities of the countries. By Florence Baingana
It is also important to note that not all development assistance to mental health is in the health budgets, and yet tracking of mental health resources often only considers funds allocated within health budgets. For example, most of the financing of psychosocial issues, whether in relation to HIV/AIDS or to conflicts, is provided through the social protection sector. UNICEF, for instance, receives funds and provides programming extensively for ‘children in extremely difficult circumstances,’ including a huge part of the resources going to psychosocial services, but this is not reflected in the health budgets or programming for UNICEF, or for the donors that provide the resources to UNICEF.
Challenges A major challenge is that of data; it is almost impossible to determine who is funding what in each of the countries or even in the disbursements of development partners. This is especially so with the move from project funding to budget support of countries. In the past, prior to the introduction of Sector Wide Approaches (SWAp), a development partner could select a health issue and provide direct support to this issue. Now, all funds have to go into a ‘basket’ that finances the countries development priorities, with the exception of HIV and AIDS, tuberculosis, and malaria. Each sector prepares a sectoral policy that provides its vision for how that sector will
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contribute to the achievement of the country’s poverty eradication action plan (PEAP) or a poverty reduction strategy paper (PRSP). If mental health is not identified as a priority, it is not possible for a development partner to fund this area, not even through support to NGOs. The first place where a bottleneck occurs is when governments determine what to prioritize and how much to allocate to each of the sectors. This is often done by the Ministry of Finance and, yet, many mental health advocates focus their efforts on the Ministry of Health. If the Ministry of Finance allocates a very small percentage of the GDP to health, the amount that can be allocated to mental health becomes even smaller. Even where donors do want to put resources into mental health, unfortunately for many countries, mental health is not prioritized in the health policy and in the health sector strategic plan, making it impossible for this support to be provided. A recent study by WHO found that 36% of countries spent less than 1% of the health budget on mental health and for many countries, the allocations for mental health have been decreasing. On the side of the development partners, mental health and noncommunicable disorders (NCD) are often not a priority. As an example, of the four biggest donors
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to global health, The World Bank, US Government, Bill and Melinda Gates Foundation (BMGF), and the Global Fund for HIV/AIDS, Tuberculosis and Malaria (GFATM), only the World Bank provides funding to non-communicable disorders. A further challenge is that the World Bank only provides loans and countries are not willing to borrow money for mental health. Countries prefer to get grant monies for mental health, thus reinforcing the stigma linked to the perception of mental health as a waste of scarce and costly resources when even the advocates believe that it should be grant funds and not loans. A further challenge is that many lowincome and some middle-income countries do not have the capacity to absorb increased resources in the mental health sub sector. There may be no mental health focal point in the Ministry of Health; or, if there is such a person, his/her knowledge and skills for planning and implementation of a nationwide program may be limited. In such a situation, development partners may be tempted to provide such resources directly to NGOs, thereby not building the capacities of the indigenous population or the development of a governmental mental health program. As an alternative, development partners could provide technical assistance to the Ministry of Health, so that a mental health coordinator could be identified and
supported as a mental health policy and program is developed.
Increasingly, there is a tension between international NGOs and governments, especially in relation to programs such as mental health where government resources are usually minimal. Client countries and INGOs are sometimes competing with the same donors for the same resources. A related challenge is that it is difficult to determine whether development assistance provided directly to INGOs actually has an impact since the INGOs report directly to the donors and may have no contact with the host government.
In some countries, a mental health focal person is also the Director of the National Referral Psychiatric Hospital. This often leads to a further challenge where mental health resources are all channeled into the large institutions that may not be accessible to a big part of the population requiring services. Whereas it is easy to advocate for increased financing of mental health through the increase of development assistance, it is also important to be careful not to increase mental health resources in countries that do not have the capacity to absorb these resources.
A question that we often do not ask is that of whether we need more funds to be allocated to mental health, through development assistance, or whether we need to better allocate and use the available funds. Should limited mental health resources be provided to governments to channel to big institutions, or should they go to INGOs where quality and state of the art services may be provided for only part of the population? How much development assistance actually gets to the target populations at the lowest level of care? Should development assistance only target technical support to policy and other higher level functions, since they are easier to monitor and evaluate? Is it sustainable for development assistance to finance delivery of mental health services?
A further issue is that there are always competing demands for the decreasing resource envelope. We can predict that the present global financial crisis is going to lead to a decrease in the amount of development assistance disbursed. It is also clear that prioritization of how and where the development assistance goes is dependent not just on costeffectiveness, but a huge part is also political. However, if the evidence for investing in mental health is weak, this makes it more difficult to make a case for increased resources. It is also not guaranteed that increasing development assistance earmarking mental health will lead to an increase of mental health components within country health budgets. The funds that go into the SWAp basket can be reallocated to a more pressing priority should that issue not receive the resources it had anticipated. Sometimes, emergencies occur, such as the breakout of an epidemic like Ebola or cholera that may necessitate the reallocation of resources. It may also be that whereas the development partner has allocated an increased amount to mental health, the country has not prioritized mental health, and the development partner cannot impose the money on the country.
Opportunities Opportunities do exist and, increasingly, development partners are recognizing the importance of mental health to poverty alleviation efforts. As examples, the African Development Bank has provided two loans to the Government of Uganda as ‘Support to the Health Sector Strategic Plan,’ that specifically target integration of mental health into primary health care. As indicated earlier, this only happened because Uganda had prioritized mental health in the Health Policy and in the Health Sector Strategic Plan.
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“Thirty-six percent of countries spent less than 1% of the total health budget on mental health.”
The U.K. Department for International Development has identified mental health as one of the priority areas for support. As a first step, a global call was put out for a study on mental health policy in Sub Saharan Africa.
Recommendations It is important to increase the public mental health capacity of development partners as well as of the Ministry of Health and Ministry of Finance staff of the client country counterparts. It would also be important for international NGOs working in the area of mental health to have a better understanding of how development partners determine and allocate resources to health priorities. One way to influence development partners is to get onto the agenda of the G8 Fora. This could be done by lobbying some of the partners who are regular members of this grouping. A good candidate could be the UK, since the Department for International Development has already identified mental health as a priority area. Another recommendation is to increase the amount of research that maps mental health within development assistance, especially the link between direct support and an increased productivity and, ultimately, poverty alleviation. It would also be important to study whether development assistance that does not specifically target mental health will lead to an improvement in mental status, especially for countries where a large part of the population is affected by conflicts, natural disasters or HIV and AIDS. All parties involved - the development partners, host government representatives and the INGOs – should have regular coordination meetings where priorities are determined, and implementation, monitoring and evaluation plans are agreed upon, including establishment of mechanisms for reporting and sharing of information. Florence Baingana is a Psychiatrist, and is currently a Research Fellow with Makerere University School of Public Health, Uganda. From 2002 to 2006, she worked as a Senior Health Specialist and as a Consultant for the World Bank. In 2000, she was seconded to the World Bank by the World Federation for Mental Health, paid for by the MacArthur Foundation. Previous to joining the World Bank, Florence Baingana was Uganda’s National Mental Health Coordinator. Her email address is
[email protected].
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Mental Health Nursing in Low- and Middle-Income Countries Mental health, which is more than merely the absence of mental disorders, is considered to be crucial to the wellbeing of individuals, societies and countries. But despite the publication of high-profile reports and promising activities in several countries, progress in mental health service development has been slow in most low-income and middle-income countries. It is estimated that 76% - 85% of people with serious mental disorders do not receive treatment in developing countries. By Rob Keukens
Worldwide, nurses are the largest group of professionals working in health care. The World Health Report 2006 indicates that there are about 39 million health service providers around the world, 16 million (41%) of whom are nurses. Nurses are the primary service providers in health systems in many countries, including serving as the main providers of mental health services. In Africa, for instance, 57% of all health care providers are nurses. A Gambian nurse estimates that in her country, 90% of all mental health services are provided by nurses.
Shortage of nurses Although 16 million nurses is a large number, there is still a huge shortage of nurses worldwide. This shortage will be aggravated in the future because of the growing global population while the number of health workers will probably remain the same or decrease. There is especially a serious shortage of nurses, and, thus, mental health nurses, in low income countries. For instance, Africa has a very low number of mental health settings and few nurses in these settings (0.32 per 100,000 population compared with 26.76 per 100,000 population in Europe). Experience from Tanzania: Many mental health nurses have lost their motivation over the years because their work seems not to be valued. While there are incentives like additional salaries and training pos-
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sibilities for nurses working in other areas, such as HIV/AIDS, no attention is paid to psychiatric nurses. The situation will be aggravated because many of the estimated 700 mental health nurses in Tanzania (pop. 34.6 million) will retire within the next couple of years. Many nurses are reluctant to work in mental health as a consequence of the stigma associated with psychiatry and the perceived danger of working with psychiatric patients. It is essential that human resources and training policies recognize the impact of stigma and discrimination on people and their families, so that mental health workers can be equipped with strategies to redress the situation. In addition, it is important to recognize that mental health workers themselves are stigmatized. “If you work there, you must be crazy yourself.” Nurses, to some extent, suffer from the same stigma as people with mental health problems and their families – they are too often invisible, voiceless, and at the margins of society. Although many people have elevated but stereotyped ideas about nurses as “Angels of Mercy,” public respect doesn’t lead to more influence or better working conditions. In many countries, the situation is aggravated because the professional establishment opposes an expanded role for non-specialists in the mental health workforce. On
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Nurses in Sri Lanka Mental Hospital
the other hand, due to the lack of psychiatrists in many low-income countries, nurses often carry out roles that are traditionally done by doctors. In a substantial number of countries in Africa and Asia, nurses are even authorized to prescribe or continue psychotropic medicines. Nurses also often leave government employment because of higher salaries existing in private practice and overseas. An example from a newspaper in Sri Lanka: “Sending housemaids abroad will cease next year. The government has taken steps to send out BSc qualified nurses to foreign countries. Nurses are in big demand in countries like the USA, Canada and many other European countries, Minister de Silva (Ministry of Health) said. Nurses, especially the trained ones, are offered lucrative jobs in those countries. Sri Lanka can earn foreign exchange from one nurse equal to that of one hundred (100) housemaids, the minister added.”
Lack of Training One well-established barrier to the scaling-up of mental health services is the inadequate number of people trained to provide care. In lowincome countries, only 0.17 nurses per 100,000 population have formal mental health education. Nursing in general, and specifically mental health nursing, does not seem to be a priority for decision-makers or educational systems; consequently,
there is not enough training for nurses in both basic and post-basic education programs making the recruitment of nurses for mental health even more difficult. While training facilities for other professionals have been developed, many countries have neglected creating training facilities for (mental health) nurses or including mental health in basic nursing training. Moreover, hardly any mental health nursing literature has been published, especially literature adapted to the local cultural context, or available in local languages. Likewise, in developing countries there is a shortage of nurse teachers, especially nurse tutors in mental health. Frequently, courses are taught by doctors with little to no didactical skills and competences. The biggest discrepancy in this respect between high and low income countries relates to whether or not nursing students can gain experience in a community mental health setting. Over 80% of high income countries provide this experience, as opposed to only 46% in low income countries. It is a vicious circle. If mental health is to be deinstitutionalized and introduced on a primary care level, well-educated nurses are needed; however, nurses can’t gain expertise in this area since there are no community based facilities.
Steps to be taken As the WHO document on Human Resources and Training in Mental Health states, several courses of action can be taken by countries to address the difficulties. Training of health staff needs to be reviewed and improved, in keeping with the
mental health needs of the population.
There is a huge need for more nurses with appropriate mental health training in low income countries. In most of these countries, the number of nurses with training in mental health is far less than the number of nurses working in mental health settings. In view of the severe deficiency of other mental health personnel in these countries, the role of nurses becomes even more critical. This implies also a trainer-of-trainers approach. To have a sustainable effect, a sufficient number of nurse trainers in mental health should be educated, both in technical mental health themes as well as in teaching methods.
a. Recognize nurses as essential human resources for mental health care Nurses play a key role in the care of people with mental disorders; this role needs to be recognized and incorporated into the overall plans for mental health in all countries. Nurses, with appropriate training, can perform a much wider variety of functions within mental health services than they are currently allotted. In one specific area, nurses often do have more responsibility. Attributable to the limited number of physicians available, in many low income countries, nurses are authorized to prescribe medication. They do so because there is no other way to get medications to the people who need them.
c. Include a mental health component into general nurse training Mental health must be an obligatory ingredient of training for all nurses because mental health is not confined to psychiatric hospitals and wards. Because there are no standards for the content of mental health training in basic nursing programs, countries’ curricula vary considerably on what is included. Many low income countries do not include any training for mental health at all, or the program is very limited.
Nurses have to be able to provide mental health care in the community, as community services should be the most easily accessible form of care. The role of nurses ought to be expanded to incorporate assessment, clinical care and follow-up, using psychosocial and pharmacological interventions. Nurses should be fully involved in the development of policy, plans and legislation and service programs. Western NGOs developing projects to support mental health in low income countries could include specific elements targeted at enhancing the position of mental health nurses in their proposals. b. Ensure that adequate numbers of trained nurses and nurse tutors are available to provide mental health care
The shortage of nurses and the enormous lack of sufficient training and literature will be a limiting factor for establishing comprehensive mental health care teams and will contribute to unmet needs in mental health in developing countries.
Nurse in Sri Lanka Reviewing Patient Records
Rob Keukens is a Mental Health Consultant for GIP and Lecturer HAN University Nursing Dept. Nijmegen The Netherlands. His email address is:
[email protected].
The International Council of Nursing defines nursing as a profession that: encompasses autonomous and collaborative care of individuals of all ages, families, groups and communities, sick or well and in all settings. Nursing includes the promotion of health, prevention of illness, and the care of ill, disabled and dying people. Advocacy, promotion of a safe environment, research, participation in shaping health policy and in patient and health systems management, and education are also key nursing roles.
Although an overall accepted definition of mental health nursing is not available, the characterization of the American Psychiatric Nurses Association is satisfactory in the context of this article. Mental Health Nursing is a specialty practice focusing on the identification of mental health issues, prevention of mental health problems, and the care and treatment of persons with psychiatric disorders. Psychiatric mental health nurses and nurse practitioners practice in acute care or primary care settings and may specialize in areas such as child-adolescent mental health nursing, geriatric-psychiatric nursing, forensics, or substance abuse.
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Addressing the Gaps in Addiction Treatment and Community Mental Health in Kisumu, Kenya Kenya, like many developing countries in Africa, has seen a gradual decline in the quality of health services, particularly in the public health sector. This has adversely affected the health status of vulnerable groups including the poor, children and women, and especially the mentally ill and addicted persons. In the absence of comprehensive government programs and adequate facilities, a huge section of the population is left out of the overall health care framework. Although there have been some level of nonstate actor inventions mainly through mission hospitals and a few non-governmental organizations, most of these service are inadequate, lack appropriate technology and relevant skills to address the widespread suffering of persons with substance related mental health problems.
By Antony Otieno Ong’ayo
Moreover, current health services mainly focus on general health problems, while services for addiction and related mental health problems do not exist especially in Nyanza province around Lake Victoria. Those seeking addiction and mental health treatment have to travel to the capital city, Nairobi, which is 350 Km away. The existing addiction treatment facilities in Nairobi are privately run and charge exorbitant prices
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SINAM’s Western Kenya Initiative Residents of SINAM’s first rehabilitation program in Mombassa
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that are beyond the reach of many addicts from poor families. Since the province has no mental health facility or services to local communities, all mental health cases have to be referred to Mathare Hospital in Nairobi, which admits patients from all over the country, often those who failed to improve elsewhere. In the foregoing, SINAM (A Substance Abuse Therapy Organization) has begun to develop a comprehensive addiction treat-
ment program that includes community mental health care and a training component that targets communitybased care workers in managing addiction and mental health. This will be implemented in partnership with Global Initiative on Psychiatry and De Witte Ruiter Stichting from the Netherlands as part of a broader collaboration for skills transfer and sharing of experiences and best practices.
The targeted area is Nyanza province in western Kenya, situated around Lake Victoria. The province has a population of 4,392,196 (as of the 1999 census) within an area of 16,162 km. The area and communities living around Lake Victoria have been, for decades, victims of political and economic marginalization by successive Kenyan governments since independence. A total collapse of major industries in this region has led to high levels of poverty and exacerbated the condition of poor health and social services for the most vulnerable groups. With its poverty rates pegged at 63%, this province leads nationally in poverty prevalence and the poverty situation is therefore associated with the spread of diseases and increased levels of addiction to alcohol and other drugs. Out of the four million people in Nyanza, the majority are young people of between 0 – 30 years of age. The age groups that fall prey to the drug dealers are 20% (10 – 15 years), 70% (18 –35 years), 10% (36 – 70 years). Alcohol, tobacco, bhang and khat are some of the substances while the youth increasingly also abuse imported, illegal substances such as heroin, cocaine, and mandrax. For instance, alcohol is most readily available to adults and to youth between 10 and 24 years; that is, children, teenagers, and young adults with 26.8% of the total number being students and 81.5% non-student drug users in Nyanza. The lowest age of reported abuse is six years old (among street children). Teenagers and young adults are the most frequently reported patients with drug-related problems, while abusers 50 years of age or more somehow manage to cope with abused drugs, mostly alcohol and bhang. The provincial capital, Kisumu, has a growing population, of about 300,000 inhabitants excluding surrounding villages. The profile is weighted heavily towards those under 25 years of age who make up about 50% of the population. Unemployment in the area is above 60% and poverty is, thus, endemic. The infrastructure for public health services in the province is on the point of collapse, while the few
> “Humane principles and well-intentioned resources targeting the addicted can provide the models needed for prevention and treatment.”
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About the community and region
available public services are extremely poor. Due to high levels of poverty, unemployment, and poor living standards in both rural and urban areas, most people resort to addictive substances and behaviors of various sorts in order to cope with their emotional and economic problems. In the context of these hardships, there is an increase in addiction to alcohol and other hard drugs in both urban and rural areas, and the increasing prevalence of HIV/AIDS related mental health problems, which are exacerbated by high levels of poverty, and the lack of appropriate intervention measures. The level of poverty and other forms of marginalization were vividly manifested during the post 2007 election violence, in which the city of Kisumu became the target of state violence. The city had the highest number of deaths through police killings during demonstrations. Most of the violence took place in the slums of Kisumu where addiction to alcohol and other substances is high and poverty is rampant. The most affected are young people between the ages of 18 to 50 years old, the majority of whom rely on odd jobs within the city and surrounding estates for survival.
problems in communities in Kenya. SINAM pursues an ethos of unconditional service to and support of the addicted regardless of ethnic or religious persuasion. Since 1997, its work has been wholly ‘drug’ centered, implementing a 24-hour program of drug services at its rehabilitation house called St. Jude’s in the city of Mombasa, Kenya. SINAM has also been running a resource centre, which gives access to information on drugs, health education and community development issues to young people, students, and the general public from the outlying slum areas of Mombasa city and surrounding villages. Since its establishment in 1997, SINAM’s outreach services revolve around the following activities and programs: • Rehabilitation of drug addicts (detoxification, recovery and after care services) • Drug Services (training, awareness creation and dissemination of information on drugs and HIV/ AIDS linked to drug abuse) • Homeless Services (street services for homeless persons and street children with drug and HIV/AIDS problems) • Resource Centre (drugs and health information documentation, library services and help line for drug abusers) • Community mental health care will be a new component to help address the wider mental health issues related to addiction and AIDS cases that develop mental complications in later stages. SINAM therefore intends to broaden its services to Western Kenya due to
About SINAM SINAM (Sisi Na Maendeleo meaning “we and progress” in Swahili) is a Kenyan registered NGO and works for the recovery and well being of drug addicts through concern, provision of care, and mutual support, giving them a program to get better perspectives of their lives. SINAM’s approach to drug addiction and mental health treatment is based on its belief that humane principles and well-intentioned resources targeting the addicted can provide the models needed to enable the establishment of effective prevention and treatment measures for drug abuse related mental health
Building the first workshop for the vocational training at the rehabilitation center SINAM in Kisumu, Kenya
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a skill training whose main goal is to equip clients to resume normal lives, and reintegrate into society as productive members.
factors related to community needs but also sustainability of the project through investment in long-term activities and in a more conducive operational environment.
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Project goal for western Kenya In view of the complexities and magnitude of addiction and mental health problems in the Lake region, SINAM’s main aim is to establish a purpose-built model drug rehabilitation facility. This facility will offer professional, humane and affordable practical help for people with drugs and mental health related problems and assist them in recovery from their mental, physical, emotional, social and economic difficulties in order to be able to step back into society. SINAM will, hopefully, thereby give them an opportunity to have a more independent position in life and the community.
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Importance of mental health care initiatives to the development and well being of communities around Kisumu City
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The interventions envisioned by SINAM in this area of mental health care are underpinned by the importance of such services to the community in the following ways: 1. Mental health and addiction are issues that affect many communities especially in the African context where mental health is either kept secret within families or neglected through lack of intervention as a result of emphasis on other forms of illnesses. A more robust response to mental health at the community level would therefore break some of the taboos around mental health but also release thousands of victims
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in bondage because of outdated traditions and unnecessary institutionalisation which reduces mental patients to objects. Because government and mission health facilities in the region have no services for the addicted and mentally ill, a huge population continues to suffer through deprivation of opportunities for recovery and becoming productive members of their families and society. Availability of information and services for community mental health care would empower the community to address the various aspects of preventive health care, with initiatives, which are cost effective at the village level. Setting up such a program would be in line with the Government’s national health policy through the Kenya Health Policy Framework Paper (KHPF) whose main important goals in addressing health problems include: Promoting and improving the health status of all Kenyans; Making all health services more effective, accessible and affordable; Restructuring the health sector to respond to reforms that would lead to improved capacity to address emerging health needs and challenges such addiction, mental heath and HIV/AIDS related problems; Raising a population tuned to health seeking behavior.
Interventions planned by SINAM In order to address some of these problems, SINAM intends to use a multifaceted approach in which treatment will be combined with long-term recovery programs and
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Individuals doing research in the Library and Resource Center
Such a vision is going to be realized through the following activities, some of which have already been started in preparation for full time programs: 1. The establishment of appropriate and relevant facilities to house the various activities and programs. Key to this goal would be the establishment of a 5 IGP (income generating projects); 2. The development of collaborative arrangements with GIP and De Witte Ruiter, Arta and other healthcare providers for capacity building and training of local health care providers and community health workers in Nyanza province through shared learning experiences and cultural exchanges on addiction and mental health care. This will be done through a training facility in which local organizations and SINAM staff will receive training; 3. The establishment of frameworks for policy dialogue with relevant authorities and also to enhance collaboration between service providers in the target region; and 4. In order to access the latest knowledge and expertise, SINAM also plans to develop working relationships for research with international and national organizations for the purpose of support and influence of Regional networks (especially in the around the Great Lakes). Antony Otieno Ong’ayo MSc. is Director of SINAM, P.O. Box 105040100, Kisumu, Kenya. Tel: +254 202042530, Mobile: +254 733 830358 or +31645116956 E-mail:
[email protected] or
[email protected].
The Mental Health and Poverty Project: Some Preliminary Findings By Alan J. Flisher, Crick Lund, and the MHaPP Research Program Consortium
The vicious cycle of poverty and mental ill-health Poverty and mental ill-health interact in a vicious cycle of deprivation and disadvantage. On the one hand, poverty can give rise to poor mental health through the stress of living in conditions of poverty and increased risk of exposure to adverse life events such as trauma and loss. Poverty places a person at risk for a number of physical or medical conditions that, in turn, can cause mental ill-health, such as malnutrition, HIV and AIDS and obstetric complications. Poverty can also make adverse educational outcomes more likely, such as school failure or drop out, which can cause mental ill-health through the stress thus engendered, social exclusion or consequent substance abuse and affiliation with antisocial subgroups. People with mental illnesses that are also poor are less likely to seek and receive treatment than their counterparts who are not poor, resulting in existing conditions persisting for a lon-
ger period of time and emergent conditions not being prevented. On the other hand, mental illhealth can cause poverty, through increased expenditure on health care, decreased economic productivity or work attendance, and exclusion from social networks that may have presented economic opportunities.
Responses to the vicious cycle One way of addressing the vicious cycle of poverty and mental illhealth is through the development and implementation of policies that address the cycle in an integrated and inter-sectoral manner. So far as mental health needs are concerned, there is a need for evidence-based interventions that are contextually salient and accessible to poor people. So far as poverty alleviation is concerned, there is a need for social, fi nancial, residential and general developmental interventions that address the needs of people with
Students in Training Workshop at the University of Cape Town
mental disorders and promote circumstances that prevent the emergence of mental disorders.
The Mental Health and Poverty Project (MHaPP) The MHaPP is a fi ve-year research program funded by the UK Department for International Development (DfID) that is based in four African countries: Ghana, South Africa, Uganda and Zambia. The project aims to provide new knowledge about inter-sectoral interventions that break the vicious cycle of poverty and mental ill-health. The first stage of the project has been completed, in which we conducted a situation analysis, partly with a view to identifying, developing, implementing and evaluating such interventions. Below we present a few details of the situation in the countries in the domains of policy, plans and legislation; district-level mental health interventions; and mental health information systems.
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Policy, plans and legislation The four countries have a variety of mental health policy, plans and legislation in place, the status and dates of which are summarized in Table 1.
Table 1 Mental health policy, legislation and plans in Ghana, South Africa, Uganda and Zambia
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South Africa
Uganda
Zambia
Policy
1994
1997
2000 (draft)
2005
Legislation
1972
2002
1964
1951
Plan
2005
-
(built into Health Sector Strategic Plan)
-
In Ghana, the vision statement of the 1994 policy includes human rights, social inclusion and some commitment to evidence-based practice. While a number of policy objectives are consistent with WHO’s mental health policy objectives, some areas are not addressed properly, particularly human rights and provisions for funding for mental health services. The current legislation, the Mental Health Decree of 1972, includes procedures for involuntary admission, accreditation of professionals and facilities and enforcement of judicial issues for people with mental illness. Several aspects of the Decree were inadequate, including non-discrimination against people with mental disorders, promotion of human rights for people with mental disorders and equitable provision of mental health care, among others. To address these shortcomings, a new draft Mental Health Bill has been developed and is currently being presented to the Cabinet. In South Africa, “policy guidelines” were developed in 1997, along with a chapter on mental health within the white paper for the transformation of the health system. These policy reforms came as part of general reform after the demise of apartheid, and marked a significant departure from previous policy. They embraced community-based care, human rights and the delivery of mental health care through an integrated package of primary health care. While there is debate regarding the status of these policy documents, a new mental health policy is in the process of being developed by the national Department of Health. There is no national strategic plan for mental health, as planning is meant to occur at the provincial level, to which health budgets are devolved. All of the 9 provinces have developed strategic plans for mental health, but these are integrated within general health strategic plans, and the extent to which mental health is addressed is varied. The apartheid era legislation was reformed with the promulgation of the Mental Health Care Act
Ghana
in 2002 which is consistent with international human rights standards, and promotes community-based mental health care.
Living conditions in poor township of South Africa
MentalHealthReforms
In Uganda, there is no official policy, but a draft mental health policy was developed in 2000. This document has informed service reforms within the country, which have made significant strides towards decentralizing care to the district level. Working within the Health Sector Strategic Plan, and assisted by grants from the African Development Bank, mental health inpatient units have been built in each of the 12 district hospitals, and training programs have been conducted for clinical officers and nurses in primary mental health care. The 1964 legislation is outdated and has a number of shortcomings, including a failure to distinguish voluntary and involuntary care, a focus on detention of the mentally ill, inadequate protection of the human rights of people with mental illness and the presence of derogatory and stigmatizing language. In Zambia, a new mental health policy was developed in 2005.
2008 (draft)
However, the implementation of this policy has been limited, partly because there is no strategic plan for mental health and mental health is not included in wider health strategic plans. A draft strategic plan is currently being developed. The Mental Health Disorders Act of 1951, inherited from the colonial era, does not provide protection for the human rights of people with mental disorders, uses derogatory language (such as “imbecile,” “idiot,” and “immoral”), and is not widely used in the provision of mental health care in Zambia. In 2006, the Ministry of Health initiated a process for developing a draft Mental Health Bill, which will repeal the existing legislation.
District mental health systems: case studies Across the four countries, specific district sites were selected as case studies to provide an in-depth analysis of district mental health services. In a central rural district of approximately 140,000 people in Ghana, there is one district hospital and 6 clinics, with no psychiatrists, psychologists or occupational thera-
pists. Mental health was widely acknowledged as a neglected area with no staff dedicated to the management of mental health services. General nurses and doctors provide care, largely for people with severe neuropsychiatric disorders such as schizophrenia, bipolar disorder and epilepsy.
service training in mental health for any health providers at the primary health care level. There are specialist psychiatric clinical officers and psychiatric nurses who provide services in some districts, but their precise distribution and number is unknown.
Information systems
In a rural district of 326,567 people in eastern Uganda, there is one district hospital with no designated mental health beds. There are no psychiatrists, psychologists or occupational therapists and only one mental health nurse. Although general nurses have received some mental health training, it was not regarded as a priority by the district health management, and there were no supervision structures in place for mental health. Referral pathways to the national Butabika psychiatric hospital were seldom followed and service users were often admitted directly to the psychiatric hospital. In Zambia, a district case study was not conducted but analysis of the general primary health care service revealed that services are centralized in the Chainama psychiatric hospital in Lusaka, with little integration of mental health into primary health care services, currently delivered largely by clinical officers and nurses. None of Zambia’s 3 psychiatrists work outside of Chainama hospital or private practice. Although nurses, clinical officers and doctors receive some mental health training in their basic training (8.7%, 12% and 8.3% respectively), there is currently no in-
The Mental Health Information system in Ghana (MHIS) is not a separate system by itself but is part of the National Health Information System (NHIS). The categories collected by the NHIS include only 4 categories for mental health: Epilepsy, psychosis, substance abuse, and neurosis. These are poorly defined, and collected differently by the community psychiatric nursing services, district and regional hospitals and district and regional health management teams. The aggregate data is poorly understood and cannot be used by policy makers, service planners or care providers.
Effects of poverty in South African township
Conclusion
> “While progress is being made on the vicious cycle of mental ill-health and poverty, much is yet to be done.” staff, facilities); and c) little use of data collected by planners, policy-makers, managers and mental health service providers for the development of mental health policy and for planning and monitoring/evaluating mental health care services. In Uganda, it was reported that poli-
cies and plans are based on routine surveillance data collected annually. However, there is a consensus that the health information and reporting system is still inadequate, especially at the district level, and that mental health data is scarce. In Zambia, a Health Management Information System (HMIS) was set up in 1996. In 2005, a comprehensive assessment of the HMIS concluded that it is well established, functional at all levels of the health delivery system, based on a defined set of indicators, and succeeds in collecting and analyzing data on a regular basis. However, mental health is not adequately addressed, as exemplified by the fact that only two disorders are included (Psychosis and Neurosis).
In South Africa, the situation analysis identified a lack of adequate mental health information to support policy, planning and management decisions at all levels of the health system (district, provincial, national). More specifically, the following problems were documented: a) a lack of nationally agreed indicators for mental health information systems; b) a lack of accurate routinely collected data regarding current mental health status, service provision (admissions, outpatient visits) and resources (budgets,
>
In a rural sub-district of 168,508 people in northeastern South Africa, there is one district hospital with 5 dedicated psychiatric beds. There are no psychiatrists, one part-time psychologist (who also serves the wider district - population 503,760) and 6 psychiatric nurses. There is a mental health nurse coordinator for the district and general primary health care nurses have received some mental health training. Assessment and treatment for severe adult disorders such as schizophrenia and bipolar disorder are provided, but there are few services for depression, trauma and the mental health needs of children and adolescents.
It is clear that interventions are required in the areas of policy, plans and legislation; district-level mental health interventions; and mental health information systems. In the second phase of the MHaPP, efforts are underway to develop, implement, and evaluate two or three of each of these interventions in each of the four countries. These interventions will contribute to breaking the vicious cycle of poverty and mental ill-health and generate lessons that may be useful to other low and middle-income countries. For further information, contact: Professor Alan Flisher (alan.flisher@ uct.ac.za) or Dr Crick Lund (crick.
[email protected]), Mental Health and Poverty Project, University of Cape Town, South Africa. http://www.psychiatry.uct.ac.za/mhapp/.
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GIP in Tajikistan: Working Towards Well-Being in all its Facets
To date, McDonalds has not established any restaurants in Tajikistan. Should we anticipate the day the first golden arched M appears as a signal of progress, or are other matters more important for the development of this central Asian country? By Ella Terburg
Agricultural activity therapy
Poverty, development, wellbeing and mental health From 1992 to 1997, a civil war raged in Tajikistan. The conflict seriously weakened the economy, leading to an increase in poverty. Since then, significant progress has been made to rebuild the country, but there is still a long way to go. In the 2007 IMF ranking by GDP per capita, Tajikistan is still 153rd of 179 countries. One of the ways in which the problem of poverty can be addressed is to improve the mental health status of a country’s population. Being vulnerable to mental illness or having a mentally ill parent increases an individual’s risk of becoming or staying poor. The loss of life opportunities such as education, career development, successful long-term relationships and being part of a caring community, damages the prospects of getting a job or staying in it. In addition, providing mental health care requires resources that take away from other needs of the country. Thus, less mental illness leads to reduced poverty.
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An additional important aspect, however, is that we believe that enhancing development relates to more than fighting poverty. Promoting mental health is – besides a way to improve people’s financial status - also a way to improve people’s well-being regardless of income or material possession. Positive relationships, meaningful activity and feeling respected and appreciated are basic needs of every human being. Thus, a fundamental principle underlying our work is to allow users of mental health care to continue to participate in society and use their potential as much as possible, while still benefiting from the necessary treatment and support. This conviction lies at the heart of GIP’s work in all of its fields of operation, including Tajikistan.
GIP in Tajikistan Since the early days of GIP’s existence, Tajik representatives have participated in our conferences, and small-scale activities were supported in this central Asian country. In 2003, our involvement gathered momentum when Medicins sans
Frontières – preparing to withdraw from the country - asked us to assess the possibilities of following up on their work in the field of mental health care. An assessment mission took place and in the autumn of that year, a local representative started developing contacts and preparing the field. In the spring of 2005, a larger-scale project, funded by Misereor, Germany, was started. In this context, two psychiatric hospitals were supported by providing occupational therapy, improving patient diets through agricultural activities, and helping improve the relationships between staff and patients. Moreover, the enthusiastic local coordinator for GIP succeeded in establishing good collaboration with the Ministry of Health (MoH) enabling us to work together towards a better overall mental health environment in the country, as well as prepare more community-based projects. Soon, a user of mental health care was hired and joined the GIP team in Tajikistan. He has since played a major role in all activities.
> “GIP’s agricultural therapy program enhances patient’s health and improves staff/patient relationships.”
>
Many other activities flowed from the first project, including the establishment of a users club, the refurbishment of a hospital wing for a semi-independent living project, a third agricultural therapy project and an art-therapy project in rent-free premises provided by the MoH. In addition, we provided Russian language literature on contemporary health care and supported several small projects aimed at providing leisure activities for users of mental health care. In October 2006, another major step was taken with the establishment of an Experts Centre on Mental Health and HIV/AIDS as part of large multinational GIP project. In November 2006, a conference was organized in Dushanbe, which had two focal points: acute crisis intervention care and user activities.
relatives, a desire for meaningful activity and recognition of their contributions, and the right to decide their own futures.
Concrete responses One of the ways in which GIP in Tajikistan currently addresses the situation at hand is to offer computer classes and English lessons for users of mental health care. The computer course was provided free of charge by a partner organization and the users learned how to use the internet, Excel and the free operating system Linux. These skills enhance their chances for finding a job. The users are already using the newly acquired knowledge in their advocacy work, where they lobby for the rights of users to obtain the services to which they are legally entitled.
Participation and respect The conference was a major opportunity to put these principles into practice. Users of mental health care played a significant role in preparing the conference, and they participated actively in the debates and seminars. Thus, the event was a rare occasion in Tajikistan for people who have a link to mental health care in one way or another – as a user, the relative of a user, professional carer or manager – to all work together and interact. A popular local newspaper published an extremely positive article which was very helpful in the fight against stigmatization of people with mental illness. The conclusions of the sessions on user issues emphasized the importance of continued care when they are back at home after discharge from hospital, in order to prevent new hospitalization. The users also indicated their interest in job opportunities; for example, setting up a catering service, and their wish to be involved in their own treatment plans.
Produce from the agricultural therapy program
Another program that demonstrates our philosophy is the art therapy project. Apart from offering a meaningful activity to users, the active involvement of the Dushanbe Institute of Art has given students and users an opportunity to interact. Equally, the artworks were presented and offered for sale at specially organized events. These exhibitions again
received positive media coverage; thus, providing additional contributions to the fight against erroneous beliefs about mental illness. In addition, the income from the sales allowed for a measure of financial independence for the activity, as new material could be bought to continue the sessions. Thirdly, in June 2008, a training week was organized for the users club. The aim of this training event was to develop the users club – which organizes outings, DVD evenings and where users interact and help each other - to a real user movement. In this movement, people are able to unite and pursue the goals that are so important for them: full-fledged participation in society, gaining respect, and having the opportunity of using their skills and capabilities.
Social prosperity As was stated above, one of the ideas raised by the users group was to set up a catering service. Perhaps, in the no-too-distant future, Dushanbe will have a new restaurant facility offering hamburgers and French fries, even though it will not be under a golden arch. In addition to promoting material wellbeing, this would be a further step in the crucial development of Tajik society by being a place where people make the most of their abilities, in full interaction with fellow citizens. A great wealth! Ella Terburg is a Freelance Project Manager at the GIP office in The Netherlands. She can be reached at
[email protected].
The expression of need for employment highlights the reality that most users in former Soviet Union countries live with a tiny state pension or are totally financially dependent on relatives. A paid job would significantly improve their financial situation. Moreover, all of these issues reflect the non-financial needs indicated above: a desire to live in the community among friends and
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Psycho-social Work with Internally Displaced People in Georgia: Problems and Solutions GIP’s Tbilisi Office is a “support organization” that provides relevant training, supervision, consultation and facilitation to the key stakeholders in the field of mental health (the professional community, governmental officials, key decision makers, mental health service users and their family members, etc.) to promote and implement relevant reforms of the mental health care system in the country. By Jana Javakhishvili and Nino Makhashvili
At the same time, GIP maintains a certain flexibility to allow for a response to certain specific events. This is true in the case of emergencies in the country, such as the August 2008 crisis in Georgia, when the prolonged frozen conflict in the Tskhinvali region of the country (so called South Ossetia) moved to the acute stage and developed into a major conflict with Russia. As a result, a wave of more than 100,000 Internally Displaced Persons (IDPs) emerged from the de facto cut region. From the second week of August, immediately after the beginning of acute conflict, IDPs were temporarily housed in the schools and kindergartens in Tbilisi, Gori (Regional Centre neighboring the Tskhinvali region) and surrounding areas, and were in acute need of material and psycho-social support.
Young girl in IDP Camp in Georgia
This paper describes the context in which GIP-Tbilisi provided psycho-social support to the survivors of the August 2008 crisis in Georgia.
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MentalHealthReforms
Some history of developing psycho-social support to traumatized populations in Georgia The phenomenon of IDPs is not new for Georgia: the country experienced a wave of approximately 350,000 Internally Displaced Persons from Abkhazia and South Ossetia (cut out regions of the country) at the beginning of the 1990s. At that time, the concept of psychotrauma was just appearing in Georgia’s mental health field. During the first stages of the conflict (early 1990s until 1995) when the first displacements occurred, no special attention was paid to IDPs by the mental health community which was, itself, in the early stages of development. At that time, IDPs fell under the responsibility of humanitarian aid distribution agencies. However, in 1995, psychosocial activities were started by several groups of professionals (psychologists, psychotherapists, and teachers), supported by the Norwegian Refugee Council and other relevant organizations. The authors of this paper were among them.
At that time, the only concept used by psychiatrists regarding psychotrauma was the diagnosis of posttraumatic stress disorder (PTSD), the prism through which all mental problems were seen. However, because of the fact that the majority of displaced persons left the conflict area before the fighting began, the cases of PTSD were very rare among IDPs in the 1990s. We began our work by searching for PTSD signs among IDPs and initially were thinking of a psychotherapeutic approach in our work. However, it appeared that the most frequent problems involved distress provoked by multiple losses (normal life style, home land, feeling of predictability of future, etc.) that damaged the problem solving capacities of IDP communities and caused a learned helplessness and victimization, both on the individual and societal levels. Thus, from the psychotherapeutic paradigm, we moved to the psychosocial support paradigm and started to help IDPs adjust to the rapidly
Since then, this initial group of 20 professionals split into several organizations with the special focus on the trauma field, some of us as trauma recovery specialists, others as conflict transformation specialists dealing with societal trauma, and, others combined these two fields. In the summer of 2007, we established the Georgian Trauma Society, uniting such organizations as GIP-Tbilisi (with the solid experience of work with IDPs, refugees and Beslan survivors), the Georgian Centre for Rehabilitation of Torture Victims (with solid experience with those who went through torture), and the Centre for Psycho-social Support “Ndoba” (with solid experience of work with IDP communities).
August crisis and “new wave of psycho-social support”: organizational problems in crisis intervention Unlike in the early nineties, the entire mental health community was ready to help the 100,000 IDPs created by the recent crisis; moreover, all relevant governmental and non-governmental organizations started to mobilize their human and material resources. The same could be said about international and other western organizations; a number of organizations from abroad provided emergency psychological support to IDPs. This big “wave of professionals,” both local and international, willing to support traumatized people, was a huge resource because of their will to help and their professional experience and expertise. On the other hand, this “wave” needed proper coordination and channeling to make
targeting the same communities at the same time and, thus, adding to the stress of multiple changes and cognitive confusion to the benefi ciaries. It was possible, however, to turn this diversity into a resource with the proper coordination. We needed to take a longer term perspective and include these groups into methodological coordination based on the system being built.
the best possible use of it. Otherwise, without enough logistical and methodological coordination, it had a potential to cause some specific problems highlighted below. Own profile driven support versus needs driven support Since becoming independent in the nineties, a strong generation of mental health specialists was educated in Georgia with the help of western organizations. These professionals, however, can not be expected to have trauma related expertise, as well as their excellent professional competencies in certain areas of mental health. Some of the mental health organizations specialize in working with people with special needs; others in the rehabilitation of psychotic patients and overcoming mental health stigma. Others specialized in specific psychiatric pharmacological treatments while others focused on psychotherapy of neurosis, etc. An initial stage of crisis existed with these professionals facing a huge need and experiencing corresponding urge to help displaced people, but not having relevant experience/ knowledge. Each specialty assisted in ways they knew best and there was a need for a proper coordination with a good referral system in order to maximize the effectiveness of each organization. The Parliament of Georgia took on the responsibility for coordinating the mental health community which, step by step, helped to build up a system where the existing professional resources can be utilized in the most effective way.
Coordination related problems: Lack of coordination, mis-coordination, over-coordination... As was noted above, the lack of coordination was an obstacle to harmonizing approaches between the professional community members and in making the most effective use of available professional resources, as well as preventing the use of methods that violate the “do no harm” principle. The coordination efforts were mixed: some were very useful and some were time consuming and ineffective. Fortunately, in the end, the roles were clarified and two major coordination processes appeared to be sustainable: one maintained by the Parliament Committee on Social and Medical Issues and another one by the United Nations. Lack of relevancy of experience in the field of capacity building In order to train certain professional groups in trauma issues, professionals were invited from abroad. While they were very dedicated and good professionals, they had worked only with the survivors of accidents in the Western countries. Working with accident survivors who continue to live in their own surroundings requires a significantly different approach than working with IDPs who have experienced massive war trauma in the form of multiple losses, uncertainty, dislocation, and poverty. While the assistance of these international professionals is very much appreciated, it is also important to map out the local resources in regions such as the South Caucasus, Balkans, or, again, in Georgia itself, as many of them have substantial experience in working with groups traumatized by armed conflict and displacement.
Quality assurance related problems Another problem during the emergency period was due to the wave of different foreign organizations who came with the kind intentions to help displaced communities; each with a different background, a huge diversity of approaches often conflicting with each other, often
> “IDPs can experience a sense of learned helplessness and victimization that should be avoided.”
GIP Intervention
>
and dramatically changed circumstances of their lives. We worked to build their capacity to identify their own needs, to prioritize them and identify community resources to respond to these needs and to solve the corresponding problems. We were focused on restoring their self efficacy and feelings of being in control of their own lives. At the same time, we were identifying those who were in an acute state and providing them with professional help. We included teams of psychologists, psychiatrists, general physicians, and pedagogues of 20 so that we had enough human and professional resources to serve those in need.
First steps in organizing psychosocial support Immediately after the crisis broke out, GIP set up emergency re-
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sponse teams to develop long-term psycho-social intervention. The emergency intervention had been funded for the past three months by the Cordaid Foundation (The Netherlands). GIP-Tbilisi, first of all, mobilized the Georgian Psycho-trauma Society and its coalition members to create a referral system within the emergency project.
• Normalization: to treat the IDP community trauma-related responses as normal reactions to abnormal situations and to communicate that to them both directly and indirectly (via each respective style of treatment); • Watchful waiting: to be alert to trauma related symptoms, by observing the dynamics on a daily basis and making a referral to a relevant trauma clinic or specialist if certain symptoms intensify or are prolonged. • Facilitation of recovery versus “patient-zation” of the beneficiaries: helping the clients by facilitating their natural recovery; helping in ventilation of trauma-related emotions; sharing corresponding feelings and thoughts; giving meaning to the events at hand, etc. without any forced “sessions” directed on forced recall of the experience.
At the same time, GIP-Tbilisi made an agreement with Caritas-Georgia to work in tandem: Caritas was distributing humanitarian aid and GIPTbilisi worked to establish necessary conditions for psycho-social interventions. The third step was to recruit psycho-social mobile teams and to provide them with any initial training for working in the field. There were six such teams of three created: one psychologist or social worker and two volunteers, a senior psychology faculty graduate and a junior psychology faculty second year student in each. Five mobile teams were working in Tbilisi and one in Gori and the surrounding area. The initial “condensed” 3 day training covered such issues as: trauma definition, syndrome of PTSD, stages and dynamics of trauma, strategies of responses, concept of watchful waiting and normalization, community assessment, needs and resources identification, active listening, and problem solving. All of these topics were included in the next round of training of the recruited staff, but on the deeper level. Since August 2008, the project served a total of 976 beneficiaries for psychosocial intervention and an indirect number of 2,000.
Methodology The basic principles of the approach were as follows: • To treat the community as a whole, including all the ages and genders;
> “Immediately after the
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>
crisis broke out, GIP set up emergency response teams to develop long-term psycho-social intervention.”
The directions of the work were as follows: • Establishing primary contact with the IDP communities. Approaching community members, listening to them, explicitly letting them know about the team’s mission, capacity and frame of action (to state clearly what beneficiaries can expect from them to overcome false expectations), and helping in ventilation of emotions and sharing of trauma related stories (for those who are willing to share, without any force). • Facilitating solutions to the adjustment related problems. Assessing community needs related to adjustment to the current situation, with active participation of the community members. Solving problems with their own resources rehabilitates a sense of self-efficacy to IDP community members and a sense of being in control of one’s own life - key points for mental health. • Information provision and reconnecting: assessing IDP communities’ informational needs and responding on them – i.e., information about different services and support opportunities; information about lost family members, relatives or friends and trying to reconnect them; or information on the future possible steps in their lives. normaliza• Psycho-education: tion, which is crucial for dealing with traumatic experiences could
and should be communicated to IDPs indirectly, via the style of treatment for their trauma related symptoms. In addition, the IDPs need to learn ways of helping and supporting each other and their children effectively in overcoming trauma symptoms (i.e. bed dreams, traumatic games,), etc. • Play- and art-therapy based techniques and educational-developmental games for children and adolescents: to organize group sessions with children and adolescents, based on games, play- and art-therapy elements, to help them ventilate emotions, overcome cognitive confusion, structure time, etc. • Educational activities for youth: to organize trainings on certain important life skills development for youngsters – such as, problem solving, conflict management, creative thinking, etc. This again helps the youngsters structure time and equips them with the skills they can utilize when finding their own place in life. • Referral: for those in need, who were revealed by mobile teams, the focus was on arranging the assistance of psychotherapists experienced in trauma recovery. For those who experienced major mental health problems before displacement, referral to psychiatric institutions was arranged, where appropriate.
Staff care From the beginning of the field work project, the methodological supervisor and the mobile teams found a balance between field work, office work (planning, reflecting on lessons learned, writing reports, studying professional literature), supervision and education. Finally the balance was found: the mobile teams were working on the field three days a week, in the office one day a week, and, on the fifth day, they all had joint supervision (done in the format of joint debriefing on the experience gained during the field work) and training. The described system of organization of work proved its effectiveness in preventing professional burn-out and made work of the teams maximally beneficial. Distinguishing basic elements of staff care, we would like to emphasize here the element of our approach:
issues in teaching how to identify trauma symptoms, how to help natural recovery, how to empower natural healing, which cases to refer and where, etc.
Emergency need for long term psycho-social work
Effectiveness of given staff care strategy became especially evident after GIP-Tbilisi consulted a number of different humanitarian and psychosocial organizations engaged in emergency response of the August crisis. In the organizations where staff care procedures were not in place, there emerged problems such as symbolizing burn out, conflict with each other and the beneficiaries, as well as traumatic repetitive behavior of field workers. When GIP-Tbilisi realized that the staff members of one organization were working almost constantly with no breaks and burn-out was clear, the following recommendations were shared with the organization: 1. to limit the working hours and days of the staff members, 2. to organize work in a way to give them time and space for planning and reflection on their activities, 3. to give them regular training in at least communication and conflict transformation, 4. to provide those team members who needed a special psychotherapeutic help (due to burn out) with such, 5. to give holidays to those who were in acute burn out condition. That was a case when burn out prevention measures due to lack of staff care and not enough organization of working process resulted in burn out, but the practice shows that the most effective method is to prevent burn out than to deal with its consequences.
UNHCR IDP housing
Synergy between GIP-Tbilisi projects Since the beginning of the first crisis intervention project, GIP-Tbilisi also became involved in three other projects, described below. The main point is that all the projects initiated by GIP-Tbilisi after the August crisis were in close and strong synergy and complement each other: • A project of Autumn Camp for IDP children and their mothers in cooperation with People in Need
> “The most effective way of dealing with staff burnout is prevention, rather than waiting to deal with the consequences”
>
clear methodology, facilitation of planning, balanced time for implementation, office work and rest, facilitation of reflection on the gained experience and learning lessons out of each, need-based training provision and taking care of both professional and personal development of the staff.
(Czech Republic). Thirty children and their 15 mothers were brought to the summer camp in Chakvi, Adjara region of Georgia, in September. Thus, they were taken out of the chaotic IDP settlements and given the opportunity to rest and receive support from psychologists, ergo therapists and pedagogues in overcoming their traumatic experiences. • A project of psycho-social support of IDPs in Tbilisi and the buffer zone in cooperation with People in Need (Czech Republic). In the framework of the given project, PIN provides humanitarian aid to the selected according to certain criteria IDP communities, while GIP-Tbilisi provides psycho-social support and staff care. • A project in cooperation with Merlin (UK) focused on training of General Practitioners in psychotraumatology. This project trained 17 general practitioners working in buffer zone villages in trauma
One important goal of the project is to ensure that the August crisis intervention work develops into longterm psycho-social intervention as an acute need in the country. Once trauma happens, especially when uncertainty becomes a way of life, a strategic approach of at least 3-5 years is required. This approach will address the psychosocial needs of the traumatized individuals and communities, prevention of the development of traumatic stress on the individual level but also to prevent development of societal trauma which has the potential of transmission from generation to generation. Unfortunately, mental health in the region is the least funded area in the health care field; the trauma field is the least funded area of mental health field. It is for these reasons that long term psychosocial projects directed at the development of a relevant system of strategic responses in targeting trauma is at risk in Georgia. It is crucial that a multi-disciplinary approach for facilitating recovery to traumatized communities as well as ongoing education on trauma issues for the general population and the media continue. GIP-Tbilisi is searching for support to continue this work, which is critically needed for the country. The August crises impact is not limited to August; it is still developing and needs strategic responses now. Nino Makhashvili is a psychiatrist and the Director of GIP-Tbilisi. She is a founder and president of the Georgian Society of Psychotrauma. Her email address is:
[email protected]. Jana Javakhishvili is a psychologist and facilitator who provides psychosocial assistance to individuals traumatized in armed incidents. She has co-authored 14 books and is the editor of 6 books. Her email addresses are:
[email protected] and janajavakhishvili@ yahoo.com.
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Hope Abandoned
The two men are standing in a demolished building that serves as a bus stop. We ask the direction to the town of Tskhinvali. One of the men points to the left and with a sad smile on his face adds: “And you are not afraid?” We drive off, carefully, take the bend around the corner and see right in front of us the barrier with a military post, guarded by a few Georgian soldiers. By Robert van Voren
We are in Nikozi, the last village before the border with South Ossetia. Through the trees we see Tskhinvali in the distance, not more than a few kilometers away. Partially or fully destroyed houses stand around us, the result of artillery and other acts of war. Every now and then a villager hurries past, looking cautiously in our direction.
Destruction of homes in Georgia
Later we explore the village, discovering one destroyed house after the other. Some are undergoing reconstruction, windows are being replaced, most of them having been blown out by explosions. Some houses are beyond repair, their carcasses silent witnesses of what happened during the month of August. Gradually the inhabitants become more receptive, greeting us, some even showing us the destruction of their homes. Two farmers with cows start up a conversation in Russian, to our surprise, without even knowing if we know the language or not.
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“There is no aggression against Russians,” says Dr. David Longurashvili, a doctor who heads the policlinic in Nikozi. “People understand it is not the Russian people who did this, but the Russian government. In schools, Russian is taught to children, just like before. Only one child initially refused to learn Russian, but when we explained to him that it is not the Russian people who hurt us, he stopped his resistance.” In addition, the policlinic has not escaped untouched. The building is heavily damaged, and all the equipment has been stolen. A Russian colonel carried the computer away, Dr. Longurashvili says, he even knows his name and the military unit to which he belongs. “I need this,” the colonel apparently said, explaining his behavior. The Ossetian warriors who followed in his wake subsequently broke into all the rooms, took away all equipment, pulled out washbasins, and threw a hand grenade in one of the rooms to finish the destruction.
Unfortunately, the Georgian authorities are slow in rebuilding this infrastructure. Only one room in the clinic is heated, equipment is minimal and most foreign aid programs are coming to an end. As a result, often medication is unavailable, even basic medication such as insulin and pills against hypertension. The latter appears to be widespread, and has led to a quick rise in the number of brain attacks. People are highly stressed; according to data of the mobile aid teams of Global Initiative on Psychiatry, 67% of the refugees they support are suffering from severe symptoms of posttraumatic stress. “The people lost all desire to live,” Dr. Longurashvili adds. “Even when the weather improves and spring starts, this will be a dead village. People don’t see the reason why they should grow vegetables or fruits.” The main reason for this is the lack of security. The RussianOssetian invasion has shattered all
New villages with emergency housing have appeared next to the road from Tbilisi to Gori, the largest town close to the buffer zones. They vary in size; the largest has 2000 houses, standing in endless rows alongside the highway. Although it is admirable that the government
has managed to construct more than fi ve thousand houses within a relatively short period, the building plans were not well designed. The houses have almost no foundation, causing moisture to creep into the walls. Many have no bathrooms, and toilets are often put up in the garden, without sewage. But what is worse: the villagers have nothing
> “The people lost all desire to live. Even when the weather improves and spring starts, this will be a dead village.”
Troop activity in Georgia
>
hopes, and the fact that it is now a border region with virtually no military presence, close to hostile territory, makes things even worse. The Georgian authorities limit the number of troops in the area in order to avoid provocations, but a side effect is that the population feels unprotected. Gunfire is often heard in the distance during the night and people report seeing strangers in their gardens. Only one-third of the population of Nikozi has returned; most are older people who feel they have nothing to loose. For younger people, in particular women, the fear is too great. Reports of women being raped by intruders are too frightening. It is not easy to discover how often this has happened as people avoid talking about it. The exact number of incidents – whether on a mass scale or not – is less important than the fear that keeps people away.
to do. The inhabitants are farmers, who are now massed together without land, and thus without the chance of taking care of themselves. There is no transportation to the city, and thus the chance of finding a job and earning a living is minimal. Most villages have no medical services; there is no clubhouse; and, there is nothing to keep the children busy and their minds off of the disaster that has
befallen them. Their days are filled with emptiness, and one does not have to be a clairvoyant to understand that disaster is around the corner. Within a year, it is likely that alcohol and drug abuse, domestic violence, and crime will be regular features of village life in these settlements. Global Initiative-Tbilisi has taken up a plan to help avoid some of these problems. Community mental health care services will be developed, with a crisis center established in Gori and mobile teams that will service the buffer zones and the refugee settlements. In addition, the organization wants to establish playgrounds, sports fields, and small clubhouses for the children of the settlements to provide activities and enjoyment but, at the same time, help them avoid the sense of desperation overtaking their thoughts. It is a small yet important step in the attempt to limit the damage of this war that knows only losers. Robert van Voren is Chief Executive Officer of GIP.
[email protected]
February2009
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Mental Health Challenges for Refugees and Displaced Persons By Ellen Mercer
Refugees and displaced persons face the largest challenges in that they have been forced to migrate owing to a well-founded fear of being persecuted for reasons of race, religion, nationality, membership of a particular social group, or political opinion, is outside the country of their nationality, and is unable to or, owing to such fear, is unwilling to avail him/ herself of the protection of that country. Refugees are individuals who cross international borders; asylum seekers are those who travel to another country for asylum; and internally displaced persons are forced to leave their homes but remain in their own countries. Refugees may have experienced the most extreme forms of trauma and torture. Mental health providers must take into consideration the cultural aspects of the individual when working with refugees. Assessment is made more difficult by language and
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cultural differences, time available for assessment, financial resources, and the shame many individuals feel about having experienced torture and related trauma. Often the signs of mental distress are related by physical symptoms, such as headache, abdominal pain, joint or muscular pain. Despite the fact that mental health issues are prevalent in refugee populations, psychosocial health of refugees is poorly addressed in most countries. In many instances, it is all that aid workers can do to provide shelter, food, and water, especially if they are refugees from war and conflict. It is a remarkable and tragic “oversight” that mental health is not a key element in every refugee resettlement program – whether in refugee camps or in final host countries.
Refugee mother with malnourished child
A positive development took place years ago when the “Torture Victims
> “It is a tragic “oversight” that mental health is not a key element in every refugee resettlement program – whether in refugee camps or in final host countries.”
>
Individuals have moved from place to place throughout history for many different reasons. The Organization for Migration estimates in 2006 that there are 200 million migrants worldwide. Women and children represent more than 50% of the total number, with children including unaccompanied minors, orphans, child soldiers, detainees, children heads of households, women and girls survivors of torture and sexual violence and the widows, the disabled, mentally ill and retarded and the elderly traveling alone. Furthermore, WHO estimates that more than 50% present mental health problems ranging from chronic mental disorders to trauma, distress and a great deal of suffering.
Relief Act” was passed by the U.S. Congress allocating funding for torture treatment centers for survivors of state-sponsored torture. This funding, while not nearly enough, was a major step in the right direction by providing funds for medical and mental health services as well as trainings for this specialized field. The funding has been renewed each year at the same level and continues to bring attention to the sad plight of torture victims.
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Other refugees and displaced persons may be, by way of personality, support, and circumstances, more resilient than others. The largest group of refugees, however, falls somewhere in the middle – those who are not covered by the Torture Victims Relief Act but who still need mental health care and often go without. These are the people who have been forced to move to a camp, where they aren’t allowed to work or be educated, or to a new country whose culture and language are so often different from their own. They have had to give up all of their possessions and often leave loved ones behind. Many have witnessed the death or disappearance of loved ones and the ending of their careers and ways of supporting themselves and their families. When working with migrants and displaced persons from other cultures, some basic guidelines apply: • Find out the appropriate means of greeting men, women, and children in a migrant’s culture. Learn the names the culture uses for emotional distress and mental illness. Many cultures understand mental illness in a spiritual or religious context. Religious or traditional healers use certain terms for such conditions and it is useful to use the same terms. • Use simple straightforward terms that are easy to understand when asking migrants about possible mental illness, such as “Are you hearing voices that other people cannot hear?” Explore this possibility in a cultural sense. • Be sure to tell the individuals that
you will not tell anyone else anything that they say and that you will not say anything about them to anyone else without their permission. All aspects of the interview will be kept private, unless you understand that they plan to hurt themselves or others. • Mental health care providers should
made responsible for providing an interpreter, especially for mental health issues which are sensitive and require a high level of confidentiality. • Address physical problems along with mental and emotional issues. • When possible, a same-gender provider for physical, psycho-
stated or implied, regularly and accurately. 4. Summarizing: Reviewing the main points discussed in a two-way communication, to ensure continuity and focus. 5. Probing: Directing the individual’s attention inward to help the counselor and the migrant
discuss with an individual from a different culture, in advance of any consultation, how much information he/she would want shared with their family and, if the individual so wishes, he/she should sign a waiver of confidentiality form. • When working with people of other cultures, it is helpful to find out as much about the country of origin as possible, reviewing cultural values, family structure, and appropriate behavior for members of the particular ethnic group. It is important, however, to remember that each person is unique and to avoid stereotyping individuals from the same culture. • Mental health interpreters should be adequately trained, adhere to all ethical guidelines for confidentiality, and efforts should be made to establish a relationship of mutual trust. Refugees should not be
logical, and spiritual care (when culturally appropriate) should be used and the same person should provide care. • Psychosocial and environmental problems should be addressed: education, occupation, housing, economics, access to health services, legal issues, and primary support group. • Structure the communication process with migrants (especially those with backgrounds different from the helper) in a way that will reduce any initial discomfort as the dialogue begins and to insure that each person knows what to expect from any consultation. Communication between individuals consists of listening, processing, and feedback and this is particularly important when working with migrants who may perceive different meanings from the communication. The following ways of accomplishing this goal are suggested by Tedla Giorgis: 1. Attending: Demonstrating concern for and interest in the client through appropriate eye contact, body posture, and verbal messages. 2. Paraphrasing: Mirroring the individual’s statements using exact or similar wording. 3. Reflection of Feelings: Expressing the essence of the individual’s feelings, either
examine a situation in greater depth. 6. Self-Disclosure: Sharing (appropriately) personal feelings, attitudes, opinions and experiences to increase the intimacy of the communication. 7. Interpreting: Presenting the individual with alternative ways of looking at the circumstances being discussed. 8. Confrontation: Pointing out contradictions in the individual’s behavior and/or statements, or guiding the client to face an issue that seems to be avoided.
African refugee children in makeshift school
Working with migrants can be an enriching experience for all individuals involved but it takes effort and patience to overcome the challenges of coming from diverse political, ethnic, and socioeconomic backgrounds. There is much to learn from each other and, if cultural respect and sensitivity are practiced, the rewards can be great. Ellen Mercer was formerly the Director of International Affairs at the American Psychiatric Association, Senior Program Officer at the U.S. Committee for Refugees and Immigrants and Deputy Executive Officer, World Federation for Mental Health. Her email address is: ERMercer@ aol.com.
February2009
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Improving Living Conditions & Promoting Reintegration of Mulleriyawa Psychiatric Hospital Patients
By Dr. Jayan Mendis
Background It has been estimated that 400,000 Sri Lankans currently suffer from serious mental illnesses, including major depression and schizophrenia. Also about 10% of the population in the country is thought to suffer from common mental health problems.
One of the wards of Mullriyawa hospital, Sri Lanka.
In 2005, more than 90% of the country’s mental health resources were concentrated in three big mental hospitals in the Colombo area, hosting approximately 3,000 patients. Large mental hospitals often produce poor clinical outcomes; they are associated with increased rather than decreased disability; and they stigmatize patients and often they are associated with serious violations of human rights. It is considered very important to reduce dependence on mental hospitals as providers of mental health care. In line with the 2005 Sri Lankan Mental Health Policy, deinstitutionalization is considered a necessary part of reforming the delivery of mental health services. It not only involves simply discharging people from long-stay hospitals, but is also a pro-
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cess involving significant changes whereby the delivery of services becomes predominately communitybased rather than institutional. Thus, together with a strategy of scaling down the capacity of the centralized mental health institutions, decentralized district-based community mental health services have to be established in Sri Lanka to ensure that the necessary infrastructure is in place to provide adequate mental health care to service users at their place of residence. Additionally, efforts need to be made to improve the living conditions of those patients suffering from chronic mental illness and in constant need of care.
Situation at Mulleriyawa Psychiatric Hospital Conditions at Mulleriyawa Hospital for women was a matter of significant national concern in 2005. Press reports from that year highlighted a range of issues for patients including women tied to beds and other very serious human rights violations. In 2007, I was asked to take over the Mulleriyawa Unit 2 administration as the Director of Angoda Mental Hos-
pital and a Consultant Psychiatrist. Before this time, Unit 2 had received little or no attention. There was minimal occupational therapy going on and discharge was merely a dream. Following the change in administration, the following improvements took place: • A dedicated group of doctors (4 medical officers) have been assigned to unit 2; • All patients have been allocated (by their last known address) to a Consultant Psychiatrist (responsible for a district of Sri Lanka); • All patient treatments have been reviewed, with a significant reduction in medication; • Patients have been categorized 1= unfit to be discharged, 2= with rehabilitation ready for discharge, 3= ready for discharge; • In less than a year, over 100 patients have been successfully discharged back to their families in the community, being followed up at their respective local community clinics, with only a few of the discharged patients returning back to Angoda/Mulleriyawa for further inward treatment; • More recently, psychiatric social workers have been allocated as
•
•
•
The facility comprises 710 women, many of whom have been residents for the majority of their adult lives, and are, therefore, institutionalized, even if – through treatment – they are technically clinically sane. Most are in their 50s, and originate from either the Western or North Western Province and generally come from very poor backgrounds. Despite strong emphasis on rehabilitation, discharging these patients has proven challenging and resource intensive; in many cases, families have moved on and are no longer traceable, meaning that patients have no option but to continue to reside at the facility for an indefinite period. This adds to the burden of care placed on the unit, and erodes the confidence and self-esteem of patients who would otherwise be discharged. There are approximately 50 women deemed able to work outside the facility, and a further 300 who could be gainfully employed within the unit. One of the wards has been converted into a day centre that provides a single large space for patients to use for either recreation or industry. Six sewing machines have been donated to the unit, and the women have shown enterprise and initiative in working with extremely limited resources to produce a broad range of handicrafts, including embroidery, tapestry, dress-making, and soft toys. Some craft fairs have been held, and some goods manufactured for a
Methodology The following activities have been identified as necessary in order to achieve the objectives mentioned above. 1. Improving the living conditions of inpatients through the provision of: • A bed and locker for each patient; • Adequate toilet and bathing facilities in each ward; • Improved lighting and drainage systems in the toilet areas; • An industrial washing machine in each ward for the washing of personal bedding and clothing; • Provision of water tanks; • Separate pantry/dining areas for each ward; and • Provision in each ward of a living room where in-patients can sit, read and watch television.
2. Establishment of independent group homes for 8 women. These homes would allow those women to live independently and to be reintegrated within the community. The women chosen for the homes would be those without mental health problems but whose families are unable to care for them or whose families can’t be traced. 3. Provision of a vehicle would allow the transportation of patients, community / nursing staff, to visit located relatives and family throughout Sri Lanka. This vehicle could also be used to support the reintegration of institutionalized patients into the local community, transport to places of employment, shopping trips, visits to the cinema and other places of interest.
boutique; but, in general, the opportunity to find an outlet for such goods has been limited and more coordination activities are needed. Similarly, the unit is wholly reliant on charitable donations of raw materials with which to produce goods.
4. Under qualified mental health staff.
General Objectives In spite of all the needs described above, this project is focused on the following two objectives: 1. To fulfil basic infrastructure requirements with the provision of an environment with sufficient infrastructure to create a more “homey” setting, and 2. To provide basic conditions to support the discharge of those patients able to live outside the hospital.
There are some women able to be discharged whose families have not been traced due to the lack of resources to do so. The facilitation of a service to carry out family tracing would probably facilitate the social reintegration of some of the patients. In summary and despite the improvements that took place in the last three years, there are standing issues that still need solutions. These can be classified as the following:
Global Initiative is working towards funding to establish at least one of two of the group homes to be used as a base for training of staff as to how to use the homes in a proper way. Experience has shown in the past that such facilities can easily change into small hospital wards if proper attention is not given to self-reliance, selfcatering and independence of the inhabitants. A short course of 5 days by a team of Dutch experts from the RIBWs would suffice to make sure that this does not happen.
1. Problems related to patient’s dignity and wellbeing with respect to the lack of adequate infrastructure; 2. Lack of social integration possibilities related to unavailable infrastructure, social networks or vocational trainings - institutionalization; 3. Lack of activities to facilitate family tracing;
We believe that great progress has been made in the situation at Mulleriyawa Hospital and we are hoping that, step by step, our goals will be accomplished.
> “Conditions at Mulleriyawa Hospital for women in 2005 included women tied to beds and other very serious human rights violations.”
>
•
per consultant, to support the discharge process; Occupational therapy has been provided by a local NGO – NEST, for a small proportion of the women; Plans are underway for the construction of an Occupational Therapy facility on the grounds of the hospital (the frame work has been erected); In the meantime, ward 18 has been emptied (patients moved to the other wards) and it is in the process of refurbishment as a Centre for Psychosocial Rehabilitation and Occupational Therapy; Patients are being encouraged to engage in social activities with the hope that they will be less institutionalized and prepared to live independently with the support of their families.
Dr. Jayan Mendis is Administrator of the Mulleriyawa Hospital, Director of the Angoda Mental Hospital and a Consultant Psychiatrist. His email address is
[email protected].
February2009
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Mental Health and AIDS as an Important Development Priority By Melvyn Freeman
HIV/AIDS as a development priority HIV/AIDS is unquestionably one of the most important international development priorities. The reasons for this are quite clear. Millions of people continue to be infected by the virus and are dying from AIDS around the world. Millions more, including children, are affected severely through, for example, the death of parents. It is now well understood that HIV/AIDS is not just a health issue, but a critical economic, social and even security threat. The numbers of infected and affected people, especially in sub-Saharan Africa, show clearly why AIDS is such a key development concern. For example, there are around 33 million people living with HIV/AIDS, with around three quarters of these being in sub-Saharan Africa. More than 2 million people die annually of AIDS. An estimated 370,000 children become infected each year. Approximately 12 million children have been orphaned by AIDS. In 2000, for the first time, the UN Security Council, recognizing the security implications of AIDS, debated a health issue and adopted Resolution 1308 (2000). This Resolution highlighted the potential threat the epidemic poses for international
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security. As UNAIDS has put it: “In regions where HIV prevalence rates are high, the epidemic destroys the very fabric of what constitutes a state: individuals, families, communities and political institutions. AIDS affects and eventually breaks down community structures. Public administration, governance and social services become unsustainable in the process, and both coping capacity and policing capacity are reduced. As a result, communal conflict is likely to increase, which is particularly true for areas with a history of violence and armed conflict.” The implications of the epidemic on macro-economics have also been found to be substantial. The mutual interrelationships between poverty and HIV/AIDS further emphasize the importance of AIDS to development. Given all the above, it is little wonder that all the major development agencies have AIDS as a central priority and that AIDS is a crucial Millenium Development Goal. Major injections of resources have been put into HIV/AIDS prevention, treatment and care and much more is planned for the future. Probably the two biggest funders are the Global Fund to Fight HIV/AIDS, Malaria and Tuberculosis and the US President’s Emergency Plan for AIDS Relief (PEPFAR). To date, the Global Fund to Fight HIV/AIDS, Malaria and Tuberculosis has committed US$14.9 billion in 140 countries to support large-scale prevention, treatment and care programs against the three diseases. Under the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR), the U.S. Government has committed US$18.8 billion to the fight against global HIV/AIDS and has passed legislation authorizing up to $48 billion to combat the three diseases over the next five years.
Why should mental health form part of the HIV/AIDS development agenda? GIP recently brought out a special issue of Mental Health Reforms
(01; 08) that clearly illustrated the inter-relationships between mental health and HIV/AIDS. In light of the evidence, we find it somewhat surprising that the very substantial development aid that has gone and continues to go into HIV/AIDS has hardly included mental health at all. To briefly highlight some of the available information: • Research in both developed and developing countries shows that around 45% of all PLHA have a diagnosable mental disorder. Thus, in sub-Saharan Africa alone around 10 million people have both HIV and mental disorder. Treatment rates for mental disorder in this group are extremely low. In addition to the emotional and mental pain and suffering experienced, the lack of mental health care and treatment also leads to significantly higher mortality from HIV/AIDS as poor mental health impacts the adherence to medication (including to ART) and affects the course of the disease through “mind/body” relationships and risk behaviors. • Around 12 million children in sub-Saharan Africa have been orphaned by HIV/AIDS. Children orphaned by HIV/AIDS show significantly higher rates of mental disorder. Children without stable family and without adequate opportunity for emotional, cognitive and moral development also pose a significant threat to socio-economic development. Mental disorder in children is a very high risk for later disorder in adulthood. • Prevention of HIV remains key to the control of HIV/AIDS. Poor mental health and substance abuse have both been shown to increase the risk of contracting HIV. Mental ill health also plays a role in the transmission of HIV with regard to people already infected. Good mental health care and the promotion of mental health (especially among vulnerable groups) are, thus, extremely
believe others are seeing them. This is sometimes termed ‘self-stigma.’ It is perhaps not altogether surprising then that a recent study in the UK, a country where treatment is very readily available and where attitudes towards PLHA are probably more progressive than many poorer countries, that around a third of PLHA had suicidal ideation.
important factors in preventing the spread of HIV. • Though direct research on the effectiveness of mental health interventions is thus far still inadequate in developing countries, we do know that cost-effective treatments for (non-HIV linked) mental health care are available and there is no reason why this treatment should not also be effective with PLHA, children, etc. The mental suffering (and double stigma) that so many people infected and affected by HIV/AIDS have to endure can be alleviated through appropriate interventions but this requires resources and training. Though mental health interventions are important because improving mental health is important in itself, it is also important because it has implications for better physical health and critically for longer term socio-economic development in poorer countries.
As an organization that promotes humane, ethical, and effective mental health care throughout the world, GIP has noted the global impacts that HIV/AIDS is having on mental health and equally the impact that poor mental health and substance abuse is having on the spread and control of HIV/AIDS and has been involved in Mental Health and HIV/ AIDS (MAIDS) programs since 2005. Thus far, the programs have been initiated in what has traditionally been GIP’s main geographical
Number of people living with HIV
In a recent qualitative study of PLHA, my colleagues and I identified three important “domains of meaning” that PLHA attributed to their infection, each associated with an external reality: having a chronic and possibly fatal medical condition; being infectious to others; and responses to preconceptions of others and society about what it means to be HIV positive. Assisting people to orient to these meanings is central to their ongoing health and quality of life as well as their future behaviors. Depending on whether a person is on treatment or not, HIV/AIDS is potentially a fatal condition with the likelihood of a shortened life, or if a person does receive treatment, a life on strong medication with potential side-effects, increased susceptibility to illness and usually additional expenses – which poor people can ill afford. In such cases, life invariably requires a change in life-goals and life-styles. Being infective to others is usually a difficult dilemma for PLHA. It implies that they need at least selective disclosure; they need to limit future relationships; they need to question deeply the wisdom of having children; and they need to take protective measures during sex. None of these is easy to come to terms with. The fact that others have preconceptions about the meaning of being HIV positive often leads the HIV positive person to perceive themselves the way they
GIPs plans for mental health and HIV/AIDS in Africa
of service development, capacity building and research in the area of mental health and HIV/AIDS. The center will be based in Johannesburg but will aim to serve the Southern African region more generally. While the details of the work are still being finalized and funding is still being sought, likely collaboration will be in the areas of: 1. introducing mental health into existing HIV/AIDS treatment programs (ART roll-out); 2. increasing counselling services as an integral part of Voluntary Testing and Counselling; 3. assisting children and families living with and affected by HIV/ AIDS; 4. caring for caregivers – formal and informal; and 5. assisting people who suffer from either depression or PTSD and are at risk for contracting HIV. HIV/AIDS is, without a doubt, one of the largest development concerns affecting the world today. But while
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region of work; i.e., in the Caucasus, Central Asia and Southeastern Europe. Expert Centers have been established in 9 countries (Armenia, Azerbaijan, Bulgaria, Georgia, Kazakhstan, Kyrgyzstan, Moldova, Serbia and Tajikistan). Now GIP intends to also move to the epi-centre of the HIV/AIDS pandemic – Africa, and particularly Southern Africa – and to lend its experience and expertise in program development, policy advocacy and change to this region as well. GIP will be partnering with one of South Africa’s premier universities, the University of Witwatersrand, School of Human and Community Development, in a process
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2007 AIDS epidemic update
this is globally recognized and accepted, the mental health issues related to HIV/AIDS are almost not recognized at all. This needs to be changed through concerted lobbying and advocacy, through introducing services and showing that they make a difference, and through building resource capacity to provide the mental health services that are necessary to make a difference. Melvyn Freeman is Consultant to GIP on Mental Health and HIV/AIDS and Visiting Professor University of Stellenbosch. His email address is:
[email protected].
February2009
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A Call to Action: Including Mental Health on the Development Agenda On the 23rd of September 2008, GIP organized and led a symposium at the World Psychiatric Association Congress in Prague, Czech Republic, with the title “Mental Health and Development Aid.” The wellattended symposium included a presentation by Dr. Benedetto Saraceno, Director of the WHO’s Department of Mental Health and Substance Abuse and Acting Director of its Department of Chronic Diseases and Health Promotion. By Benedetto Saraceno
Dr Saraceno’s provocative presentation posed a question and, likewise, a challenge to the audience and to the broader mental health community. He agreed with other speakers that mental health has not been prioritized by development assistance actors, whether governments, multilateral institutions or NGOs. However, he questioned whether the lack of attention to mental health in development circles globally is a consequence of the failures of these actors or whether the fault may lie with mental health professionals and advocates who have not made a sufficient case for attention to mental health care in the development arena. “Why is Mental Health not receiving support from the development community?” he asked the audience. The answer, in his view: “In the past 15 years we have been very good at providing evidence of the problem, but have not captured or promoted mental health interventions as solutions.” Compared with polio eradication and bed nets to fight malaria, where tangible impacts have been measured and
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actively promoted, the mental health community has not chosen this road. As he knows from direct experience in his role at the WHO, donors involved in international development are deeply concerned with evidence of the positive impacts of different interventions. He argued, therefore, that the onus lies on mental health professionals to gather and provide arguments for the tangible, measurable benefits of mental health interventions in, for example, decreasing suicide or alcohol-abuse. Dr Saraceno recognized that this would be an uphill battle due to the fact that development donors generally think in societal terms and less often address development through improvements in the individual well-being of smaller numbers of individuals, even if improvements in adherence to human rights were involved. Thus, he challenged further, “Even if we could show the difference that mental health interventions can make, the key question is whether it would actually influence development priorities.”
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What is clear is that improving health in general does make a difference in achieving development goals and perhaps a special case needs to be made for mental health in this context. But most of all, Dr Saraceno feels that the mental health community must question itself carefully as to whether it is pursuing the right strategy in arguing for attention from the development community to mental health in developing countries. The strategy, in Dr Saraceno’s view, should involve a more solutionbased approach and the collection and promotion of evidence on the impacts of mental health activities. Likewise, it should focus on demonstrating the linkages between individual development (due to improved mental health care) and collective development. Dr. Saraceno is the Director of the World Health Organization’s Department of Mental Health and Substance Abuse. His email address is
[email protected].
Russian Summaries
By Elena Mozhaeva абсорбировать дополнительные ресурсы в существующую систему психической помощи, или же значительные средства оказываются направлены в большие больницы, недоступные для большей части населения. В этой связи необходимо расширять сегмент помощи в сфере психического здоровья со стороны организаций, оказывающих ПРС, а также изучить место и роль раздела психического здоровья в помощи в развитии. Речь идет о научных исследованиях.
Обращение к читателям Мировое сообщество в последнее время находится в глубоком шоке. Банковский кризис быстро перерос в спад экономики. Конца туннеля не видно, а последствия на этой стадии трудно предсказуемы. В то же время, люди с проблемами психического здоровья, проживающие в развивающихся странах, постоянно пребывают в ситуации всестороннего кризиса. Для них это ‘’норма’’ жизни. Известно, что проблемы психического здоровья – малопривлекательная тема для любых доноров. Правительства обычно не относят ее к приоритетным направлениям, и таким образом она не попадает в программу помощи развивающимся странам (ПРС). Если какой-то компонент и включается, то это обычно травма или посттравматическое стрессовое расстройство (ПТСР), но и этот сегмент нередко быстро распадается после ухода иностранных специалистов, так как он оказывается недостаточно структурно вписан в систему помощи на местах. Текущий кризис может привести к новым упущенным возможностям в области ПРС в сфере психического здоровья.
Психическое здоровье и помощь в развитии Флоренс Байнгана В развивающихся странах разделы психического здоровья и неинфекционных болезней обычно не попадают в программы помощи в развитии. На развитие служб психического здоровья обычно не берутся займы, так как считается, что пациенты с психическими расстройствами никогда не восстановятся и не смогут заниматься продуктивным трудом. Предпочтение отдается грантам, что только усиливает стигму вокруг пациентов. К тому же многие страны с низкими и средними доходами не в состоянии SINAM staff, Kenya
Психиатрическая сестринская помощь в странах со средними и низкими доходами Роб Кейкенс Несмотря на высокопоставленные отчеты и многообещающие действия, в странах с низким и средним доходом сектор психического здоровья развивается медленно. В настоящее время лечение оказывается недоступным для подавляющего большинства людей, страдающих психическими расстройствами (76-85%), хотя такое лечение существует, оно эффективно и сравнительно недорого. Самой большой группой специалистов, работающих в медицине, являются медицинские сестры. Их 16 миллионов, но их в то же время очень не хватает. Многие медсестры не хотят работать в системе психического здоровья по причине стигматизации всего, связанного с психиатрией, а также из-за предполагаемой опасности работы с психиатрическими пациентами. Многие из них не имеют адекватной подготовки для работы с психически больными, и во многих развивающихся странах системы подготовки психиатрических медсестер просто отсутствуют. Соответствующий документ ВОЗ о человеческих ресурсах ставит вопрос о признании медсестер/ братьев в качестве необходимого человеческого ресурса для системы оказания помощи в области психического здоровья; об обеспечении адекватного количества подготовленных сестер и их тьюторов для обеспечения оказания помощи, и включения темы психического здоровья в общую программу подготовки среднего медицинского персонала.
Проблемы лечения зависимостей и психическое здоровье в сообществе Кисуму в Кении Антони Отьено Онгьяно В Кении, как и во многих других развивающихся странах Африки, отмечается снижение качества медицинской помощи. Это особенно
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сказывается на здоровье уязвимых групп: бедных, женщин и детей, и особенно людей, страдающих психическими и наркологическими заболеваниями. Людям, нуждающимся в помощи, приходится ехать за помощью в столицу Найроби – за 350 км. Существующие наркологические заведения в Найроби являются частными и запрашивают за свои услуги немыслимые цены. Организация SINAM положила начало всесторонней программе лечения зависимостей с компонентом тренинга для специалистов, занятых в этой области. В программе участвует Глобальная инициатива в психиатрии (ГИП). Психическое здоровье и бедность: предварительные итоги проекта Алан Фишер, Крик Лунд и консорциум исследовательских программ MHaPP Бедность и психическое нездоровье образуют порочный круг. С одной стороны, бедность способствует плохому психическому здоровью из-за стресса бедности и повышенного риска воздействия неблагоприятных жизненных событий на физическое и психическое здоровье человека. Бедность также подразумевает неблагоприятные возможности для обучения детей, их социальную изоляцию, последующее злоупотребление психоактивными веществами и вовлечение в деятельность антисоциальных групп. MhaPP – это пятилетняя британская программа, которая осуществляется в четырех африканских странах: Гане, Южной Африке, Уганде и Замбии. Предварительные результаты свидетельствуют о необходимости интервенций в политику медицинской помощи, ее планирование и совершенствование законодательства; интервенций на уровне местных сообществ и совершенствование информационных систем в системе психического здоровья. ГИП в Таджикистане: к всестороннему благополучию Элла Тербург В период с 1992 по 1997 в Таджикистане бушевала гражданская война. Этот конфликт заметно ослабил экономику страны и способствовал усилению бедности, что особенно сказывается на людях, страдающих психическими расстройствами. Представители Таджикистана участвовали в конференциях ГИП с самого начала. В 2005 был начат крупномасштабный проект, связанный с развитием терапии занятостью в двух психиатрических больницах и улучшением питания пациентов через их участие в сельскохозяйственной деятельности, а также улучшением терапевтических взаимоотношений между медицинским штатом и пациентами. В настоящее время ГИП в Таджикистане организовал уроки компьютерной грамотности для потребителей психиатрической помощи. Навыки работы с компьютерами повышают их шансы на обретение трудовой занятости. Также реализуется программа арт-терапии и клуба для потребителей психиатрической помощи.
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MentalHealthReforms
Elderly woman in IDP camp in Georgia
Психосоциальная работа с внутренне перемещенными лицами в Грузии: проблемы и решения Яна Явакишвили и Нино Махашвили Эта статья описывает обстоятельства, в которых офис ГИП в Тбилиси обеспечивал психосоциальную помощь людям, пострадавшим от кризиса в Грузии в августе 2008 года. Речь идет о более чем 100.000 внутренне перемещенных лиц, вынужденных покинуть регионы, фактически отрезанные от страны. Их временно разместили в школах и детских садах в Тбилиси и Гори, и эти люди остро нуждались в материальной и психосоциальной поддержке. Тема травмы среди внутренне перемещенных лиц не популярна среди специалистов, потому что они не совсем понимают природу травматического стресса в таких обстоятельствах, и не очень способны идентифицировать расстройство и помочь людям на индивидуальном уровне и уровне сообщества. Сразу после возникновения кризиса ГИП создал бригады немедленного реагирования для осуществления долговременных психосоциальных интервенций. Был проведен интенсивный специализированный тренинг мобильных бригад по темам дефиниции травмы, синдрома ПТСР, стадий и динамики травмы, стратегий ответа, концепции ‘’внимательного ожидания’’ и нормализации, оценки в сообществе, оценки потребностей и ресурсов, активного выслушивания и разрешения проблем. В статье описываются направления работы и ее особенности в данных условиях. Надежды нет ‘’У нас нет агрессии к русским. Люди понимают, что дело в русском правительстве. В школах дети продолжают изучать русский язык – как это делали раньше,’’ – говорит врач поликлиники в Никози. Война не обошла это здание: оно разрушено, а все оборудование разграблено.
Русский полковник унес компьютер и объяснил это тем, что ‘’он ему нужен’’. Напоследок, чтобы довершить разрушение, брошена граната. Инфраструктура восстанавливается очень медленно. Во всей клинике лишь одна комната отапливается, оборудование – минимально, а большинство программ зарубежной помощи – в стадии завершения. Грузинские власти ограничивают количество войск в этом регионе, чтобы избежать провокаций. ГИП разработал план по оказанию помощи в пострадавших регионах. Вызовы психического здоровья для беженцев и перемещенных лиц Эллен Мерсер На протяжении веков люди переезжают из одного места в другое. В 2006 количество мигрантов в мире оценивалось в 200 миллионов. Беженцы и перемещенные лица сталкиваются с драматическими вызовами в своей жизни, когда они вынуждены сменить место жительства из-за обоснованного страха, что их будут преследовать по религиозным или национальным мотивам, изза принадлежности к определенной социальной группе или из-за политических взглядов. Автор приводит классификацию мигрантов, в которой выделяются поселенцы, политические ссыльные, лица, ищущие убежища, беженцы и перемещенные лица. Несмотря на широкую распространенность проблем психического здоровья среди беженцев, в большинстве стран вопросы психосоциального здоровья этой категории лиц не привлекают достаточного внимания властей. В статье даются базовые рекомендации относительно работы с мигрантами из других культур. Улучшение условий содержания пациентов и их реинтеграция в психиатрической больнице Муллериява Джаян Мендис В настоящее время в Шри-Ланке тяжелыми психическими заболеваниями страдает около 400.000 жителей. И около 10% населения испытывают проблемы психического здоровья. 90% ресурсов в этом секторе сосредоточено в трех больших психиатрических больницах на 3.000 коек. Больницы часто дают плохие клинические исходы, повышают вероятность инвалидизации и способствуют стигматизации пациентов. С 2005 в стране осуществляется политика деинституциализации с развитием новых форм работы с пациентами. Одновременно улучшаются условия их содержания в больнице, создается ‘’жилье под защитой’’, решается вопрос о приобретении транспорта, который будет, в том числе, использоваться в целях реинтеграции пациентов в местное сообщество.
африканских странах к югу от Сахары таких насчитывается около 10 миллионов. В этих же странах 12 млн. детей стали сиротами из-за ВИЧ/ СПИД родителей. Известно, что риск заражения ВИЧ повышен в условиях плохого психического здоровья и злоупотребления наркотиками. В то же время существуют эффективные и экономичные интервенции в сфере психического здоровья, которые в состоянии понизить эти риски. ГИП в сотрудничестве с одним из местных университетов планирует открыть в Йоханнесбурге специальный региональный центр, в задачи которого входит: (а) включение раздела психического здоровья в существующие программы лечения ВИЧ/СПИД; (б) развитие консультативных служб; (в) помощь детям и семьям с ВИЧ/СПИД; (г) помощь специалистам; (д) помощь людям, страдающим депрессией или СДВГ, с целью профилактики ВИЧ/СПИД. Призыв к действию Во время недавнего Конгресса ВПА в Праге ГИП провел симпозиум на тему ‘’Психическое здоровье и помощь развивающимся странам’’. На симпозиуме выступил директор Департамента ВОЗ по психическому здоровью и злоупотреблению психоактивными веществами д-р Сарачено. Он отметил, что сектор психического здоровья не относится к приоритетам в планах помощи в развитии. Проблема существует, но за последние 15 лет никаких решений не предложено. Д-р Сарачено признал, что доноры обычно подходят с позиций общества в целом, и в меньшей степени готовы работать с проблемами индивидуального благополучия небольших, но очень уязвимых групп населения, к которым относятся люди с проблемами психического здоровья. Новая стратегия, с точки зрения Сарачено, должна быть нацелена на поиск решений, а также сбор и распространение данных об эффектах изменений в сфере психического здоровья.
GIP associate Rob Keukens with one of the patients at Mulleriyawa
Психическое здоровье и СПИД как важный приоритет в развивающихся странах Мелвин Фриман По данным исследований, примерно 45% всех людей, живущих с ВИЧ/СПИД, страдают какимлибо психическим расстройством. Только в
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Other themes addressed by Global Initiative on Psychiatry to be covered in future issues of Mental Health Reforms:
• Forensic Psychiatry and Prison Mental Health
• Mental Health and Human Rights
• Child and Adolescent Mental Health
• User Involvement in Mental Health Services
• Community Mental Health Care
• Substance Abuse Prevention
Global Initiative on Psychiatry Global Initiative on Psychiatry (GIP) is an international not-for-profit organization for the promotion of humane, ethical and effective mental health care worldwide. GIP is registered in Hilversum, The Netherlands, and works closely with its network of regional centers in Lithuania, Bulgaria and Georgia and a country office in Tajikistan, as well as with numerous NGOs, governmental and international organizations. In addition to being a major contributor to improved mental health care systems in Central and Eastern Europe and the Newly Independent States (CCEE/NIS), GIP has also begun working in other regions of the world. In all regions our goal is to empower people and help build improved and sustainable mental health services that are not dependent on continued external support.
Photography The photographs in this issue were taken by the staff of GIP, authors of the articles, or other parties. The individuals portrayed were aware that their photographs might be published.
GIP-Hilversum (International Office) P.O. Box 1282 1200 BG Hilversum The Netherlands Tel.: +31 35 683 8727 Fax: +31 35 683 3646 e-mail:
[email protected] www.gip-global.org
GIP-Tbilisi 49A Kipshidze Str., Tbilisi 0162, Georgia Tel.: +995 32 235 314 / +995 32 214 006 Fax: +995 32 214 008 e-mail:
[email protected] www.gip-global.org
GIP-Sofia 1 Maliovitsa str. Sofia 1000, Bulgaria Tel.: +359 2 987 7875 Fax: +359 2 980 9368 e-mail:
[email protected] www.gip-global.org
GIP-Vilnius M.K. Oginskio g. 3 LT-10219 Vilnius, Lithuania Tel.: +370 5 271 5760 / +370 5 271 5762 Fax: +370 5 271 5761 e-mail:
[email protected] www.gip-global.org / www.gip-vilnius.lt
GIP’s General Board Robin Jacoby, Chair (UK) Jaap van der Haar, Secretary/ Treasurer (NL) Maarten Boon (NL) Nicoleta Candea (RO) Clemens Huitink (NL) Rolf Hüllinghorst (DE) Lars Jacobssen (SE) Dainius Puras (LT) Dick Raes (NL) Simon Surguladze (GE) Peter Tyrer (UK) Conny Westgeest (NL)
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