© Sara Creta/MSF

Mental health

This World Mental Health Day, hear stories from our patients and staff in Bangladesh, Colombia and Congo

We have been caring for patients’ mental health for more than 20 years

Our teams provide emergency medical aid in catastrophes all over the world — armed conflicts, natural disasters, famines and epidemics.

MSF doctors and nurses are often seen treating physical ailments: bandaging the war-wounded, rehydrating a cholera patient, performing an emergency cesarean section.

But for people who have lived through terrible events, the psychological consequences can be severe.

In 1998, MSF formally recognised the need to implement mental health and psychosocial interventions as part of our emergency work.

World Mental Health Day 2017

This World Mental Health Day, we take a look at Bangladesh, Colombia and Democratic Republic of Congo to show how we are 'Healing Minds' across the world.

Dhaka, Bangladesh

Violence at home can have a devastating impact on mental health. In Kamrangirchar, MSF counsellors are helping women to cope. Click 'Enter' below to find out more.

Bangladesh: "Now I am inspiring others"

Now I am inspiring others

Violence at home can have a devastating impact on mental health. In Kamrangirchar, Bangladesh, MSF counsellors are helping women to cope.

KickerThis is a kicker.

> Before, I had no courage to help other women because I was afraid of my husband, says Saliha, speaking rapidly in the afternoon heat. But now, I have overcome all of my fears and anxieties.

Saliha is a patient at MSFs womens health clinic in Kamrangirchar, a densely populated slum in the south of Dhaka, the capital of Bangladesh.

In three brightly painted rooms, the team supports women like Saliha \- survivors of sexual or gender\-based violence. While this can include victims of sexual assaults committed by strangers, in Kamrangirchar it primarily means women who have been abused at home, by their husbands or another family member.

**The women who come to our clinic are physically abused by their husbands. They are coming to us because they are totally devastated.**

Rupa, MSF counsellor

Saliha has survived abuse first from her father and then from her husband. She is, in some ways, typical of the women who come to the clinic. We see lots of cases where young women are being abused by their intimate partner and other family members, and it makes them really at risk of developing mental health disorders, explained Mitu, the mental health supervisor at the clinic.

> **"I was constantly being beaten and verbally abused"**

They develop depression, anxiety and sometimes theres a really high risk of suicide.

The violence had a devastating effect on Salihas mental health. "He used to throw me out of the house whenever he was angry. I was constantly being beaten and verbally abused," she explains. "Afterwards, I would take sleeping pills, or cut my hand, or try to hang myself. I couldnt tell my parents about that because this was my marriage."

**Research shows suicide rates are very high for survivors of intimate partner violence: they think it is the only solution**

Mitu, MSF Mental Health Supervisor

For many women, it is not only the physical violence they face that has an impact on their mental health. Although she'd been a good student, Salihas husband pressurised her to stop going to school and to have a baby \("I thought that he might change after the birth," says Saliha.\) He beat her while she was pregnant.

Family members can also play a role. Saliha's mother\-in\-law never approved of the marriage and made Saliha go hungry by hiding the family's food from her.

> '**In a survey of Bangladeshi men, 61 percent strongly agreed with the statement,** **there are times when a woman deserves to be beaten**'

As Saliha's experience shows, intimate partner violence goes beyond sexual or physical behaviour. It can include all kinds of abusive behaviour, including emotional abuse, controlling behaviour, coercion and financial abuse.

When I worked as an outreach worker I went door\-to\-door and got to know people. But peoples outside is different from their inside. We cannot see our patients just by looking at the person, we need to know deeper. So counselling is the place we come to know patients deeper, their pain, their sorrows.

Nargis, MSF counsellor

A large\-scale survey of Bangladeshi women found that 72 percent had experienced some form of intimate partner violence in the past 12 months. And in a survey of Bangladeshi men, 61 percent strongly agreed with the statement, there are times when a woman deserves to be beaten. But, despite the prevalence and severity of the problem, its not widely discussed. Seventy\-three percent of women surveyed in Bangladesh who had experienced abuse reported that they kept it secret, telling no one what theyd been through.

Leah, one of the clinics team of passionate, committed counsellors, explained some of the reasons why: They do not know that this is a type of abuse. They think it is the husbands right to beat them that beating them is his moral right. "Especially in Kamrangirchar, there are a lot of rapes committed by husbands, but our patients are not ready to accept that the husband can rape them too. They do not understand that they are abused.

There are also very limited options for women in abusive relationships. Most dont have the money to live independently, and families may not have the funds to support them. Even when money isnt an issue, the stigma of being a divorced woman in Bangladesh is immense and can make basic things like renting somewhere to live a challenge. The lack of options leaves many women stuck in violent relationships, often isolated and struggling to cope.

> **After coming to the clinic, I got the courage to overcome this day\-to\-day fight**

Ive had people ask, 'well what can we do?," says Cindy, the mental health officer for the project. "Its not going to change, so why are you providing services if your patients just go back to the same situation over and over again? But for women like Saliha, counselling can be transformative. "Now my mental trauma is gone," says Saliha. "After coming to the clinic, I got the courage to overcome this day\-to\-day fight. I learnt how to deal with my husbands abuse."

Patients are actually shocked to be treated like a human person... and so many that are suicidal, theyve lost hope, just that moment of restoring human dignity is life\-giving to them

Cindy, MSF mental health officer

While they may experience continuing violence at home, counselling gives these women a space to talk, to make sense of their experiences and to discuss safety plans. How to live better physically and mentally with these problems, as Fatima, one of the counselling team, succinctly puts it.

This in itself can make women safer, Mitu, the mental health supervisor explains. Depression and anxiety can put them at higher risk of violence because "they may be keeping themselves away from daily life, not functioning, leading to more problems with their family life."

When I began counselling, I was working with people affected by the Rana Plaza disaster and I was scared. Being a tender\-hearted person, I was afraid to hear the pain of people. Then as I have continued doing this job, I began to feel good that I have the opportunity to hear their problems and can give them support. This is my inspiration. It is mental support. Not everyone is able to provide it.

Fatima, MSF counsellor

Counselling that helps women re\-engage with their families not only keeps them safer, but is also better for their children. Unfortunately, when mums are stressed by violence from their partner, they often become abusive to the children, explains Cindy. And studies have shown that growing up in violent households is devastating for childrens development: they cant focus in school, they become aggressive and suffer the same as if they were being abused directly. "So these children are the next generation of traumatised family members who are more likely to go on and repeat these patterns.

It was so painful, Saliha says, thinking of how her husband would beat her in front of their little girl. I was thinking she is so young. When she grows up, what will she have learnt? What I faced in my childhood, will she grow up in the same situation as me? I do not want my child to grow up in this atmosphere." The team in Kamrangirchar hope to expand the counselling service to offer sessions specifically designed to meet the needs of children growing up in violent households.

In the meantime, they continue to reach out to the most vulnerable. As well as counselling services, the clinic offers medical care for new and expectant mothers targeting their services to women aged under 25. As the slight figures in the waiting room show, many are much younger.

As patients wait for their appointments, the counsellors take advantage of the captive audience. Using a laminated set of brightly painted pictures, Leah talks to the women about early marriage, mental health and intimate partner violence. Shy at first, the women are soon engaged, calling out the answers to Leah's questions. In their medical appointments, they will be asked about the situation at home and offered a referral for counselling if they need one.

> **'Often women think they deserved it because the perpetrators make them feel like that.'**

So far this year over 600 women with experience of intimate partner violence have begun counselling in Kamrangirchar. The team is working hard to educate the community and spread the message about the services that are available. Payel, the information, education and communication officer, sees changing people's attitudes as her biggest challenge.

Often women think they deserved it because the perpetrators make them feel like that. Its your fault I beat you. It's your fault I behaved like that. To break that notion is really difficult. We think it will take a long time to remove these things. But we are trying to come up with different strategies to break this and we are really hopeful one day well do it."

We have to raise our voices against abuse. Today one raises her voice, tomorrow another, and one day the whole world will speak out, perhaps then the violence\-makers will become scared.

Leah, MSF counsellor

Saliha is also hopeful. In Bangladesh, ladies or wives used to say, where will we go? We cant go back to our parents, so we have to tolerate this torture.

My opinion is completely different. Women have the power to fight back. Why should they tolerate their husbands tyranny and oppression? Why are they not coming out from this situation? It is very important to change womens mindsets. Women need to come forward and show their power to men.

[Find out more about MSF's mental health work around the world >](\-health)

Mweso, Democratic Republic of Congo

Our team in Mweso, Democratic Republic of Congo, are living through the same trauma as their patients. Click 'Enter' below to find out more.

DRC: "There is no health without mental health"

There is no health without mental health

MSF staff in Democratic Republic of Congo are living through the same trauma as their patients

KickerThis is a kicker.

> On the edge of a copse of eucalyptus trees, a play is under way. Its a familiar tragedy with an identifiable cast: a drunk abusive father, a put\-upon wife, and a daughter on the cusp of womanhood.

Whats not so typical about this theatrical display is its actors. When youre displaced from your home, your thoughts can be displaced too, says Sifa Clementine. Sifa oversees MSFs mental health activities in Mweso, a small town in the east of the Democratic Republic of Congo. Today, Sifa and her team are running a theatre production on sexual violence for the local community. The setting is the displacement camp that sits across the road from Mwesos General Hospital, where Sifa and her team work. The actors in the play are all MSF mental health counsellors. Over the course of the next three hours, the team connects with the 200\-strong audience through song, dance and drama. At the end of the play, theres a valuable moment for the audience to reflect on what theyve seen, as a form of group discussion. The event is designed to inform the people of the camp that MSF is in the community, and is there to listen. When we see a problem in the community, we act out these problems and educate in this way. Often, a person's behaviour is affected by what they have gone through. That is when behaviour changes." Referring to the character of the daughter in the play, Sifa goes on to explain: In her village, for example, she didn't drink alcohol, but now she does. She steals food in the house and she sells it for drinks. The sketches show people what can happen, and how they can overcome these problems.

MSFs mental health work in Mweso began in 2009, helping local communities and people displaced by conflict. The North Kivu region of Congo that borders Rwanda and Uganda, and home to Virunga National Park, has been in a state of constant unrest since the Great Lakes Crisis that began after the Rwandan genocide in the mid\-1990s.

The second largest country on the African continent by area, Democratic Republic of Congo is a fragile and conflict\-affected state and receives more aid from MSF than any other country in which we operate. The team of psycho\-social counsellors that Sifa supervises is drawn from the communities surrounding Mweso.

They connect with their clients using empathy, by creating a safe and secure environment where they are able to work through the traumas they have lived. Coming from the same communities as their clients, the Mweso team understand all too well the social taboos around mental health, as well as the traumatic events people are subjected to on an almost daily basis. Conflict, armed robberies, and sexual and domestic violence are just some of issues people face in North Kivu.

Theatre is one of the many interventions the team provides. Along with psycho\-educational activities such as this, Mwesos mental health team also provide therapeutic counselling for trauma related issues \- such as sexual violence, psychological first\-aid, psycho\-social stimulation for nutrition, individual counselling and support groups for people living with conditions such as HIV, TB and diabetes, as well as referrals for psychiatric care.

As counsellors, we help our clients by listening to them, but we can also connect with them over our shared experiences _\- Imani Stanley_

I was constantly worried and still occasionally have flashbacks, says Imani Stanley. Stanley began his MSF career in 2008 as a guard in our Kitchanga project, an hours drive south of Mweso. His intelligence and initiative saw him progress quickly to becoming a counsellor he studied Psychology at university in Goma and speaks six languages, including English, French, and four local dialects. He was recently promoted to an Assistant Administrator. In 2013, Stanley witnessed the horrors that many people in North Kivu have become accustomed to. In February of that year, the conflict reached Kitchanga. I was working in Mweso at the time, but my family were living in Kitchanga. We had two houses, one for me, my wife and children, and one for my mother, says Stanley. Thankfully, most of my family fled before the fighting, but five members of my family werent so lucky. I lost three of my cousins and my two sisters\-in\-law. Both my mothers house and mine were completely destroyed. Everything that we had invested in our family disappeared.

> **As counsellors, we help our clients by listening to them, but we can also connect with them over their shared experiences**

While Mweso and the surrounding area havent seen that level of fighting in the past four years, there is almost constant low\-level conflict between armed groups, and people are regularly subjected to violence. About two weeks ago, says Stanley, two of my cousins and my uncle came face\-to\-face with bandits on their way to their field, next to a small lake near Kitchanga, and were fired upon. They took refuge in the lake, but the bandits surrounded the shore. We found their bodies three or four days later and we buried them there. It hasn't even been two weeks since I experienced a death in my family. Its hard to imagine being able to psychologically come back from these events, but through Stanleys training, hes found ways to cope.

As counsellors, we help our clients by listening to them, but we can also connect with them over our shared experiences, he says. While this might not be common practice elsewhere, this method has helped to break down barriers in Congo, to connect with people initially sceptical to the benefits of mental healthcare. When someone comes to me despairing that he has lost his house, I say, Ah, you have lost a house, I understand that you are very deeply affected. I was like that too. Our sessions are, of course, for the benefit of our clients, but reflecting on our shared experiences allows us as counsellors to be comforted. We are reassured that other people are also affected .

We see that if were faced with the same problems as our clients, we can also cope and life can go on _\- Jaqueline Dusabe_

Jaqueline is a widowed mother of six children, and has been working as an MSF counsellor since 2009. She echoes Stanleys sentiments: Working with our clients really helps us. We see that if were faced with the same problems as them, we can also cope and life can go on. It helps us manage our emotions, especially as were in the same territory as them violence, traumas; we live them, too. In 1996, at the height of the Great Lakes Crisis, Jaqueline and her family were forced from their home. For five months, they slept in the bush, with nothing but a sheet of tarpaulin for bedding.

> **A lot of people \[in Congo\] display \[aggressive\] behaviour that, to the untrained eye, wont be seen as psychologically abnormal**

We slept on the ground, no mattresses, nothing else, Jaqueline explains. My little sister died during the war, along with her baby. We never found her body. At that point I was affected, for sure. I wasnt sure she was dead. I held on to the belief that she was alive. But what makes me happy, what helps me is that she left a son, her first child, who stayed with my father. Hes a big boy now. Thats something that makes me feel better, I can see her presence in him.

As a counsellor, Jaqueline has a fervent belief in the power of mental healthcare. However, shes not oblivious to the fact that mental health problems are sometimes a taboo subject in the community. When we say someone has a mental health problem, people right away begin to talk about madness or craziness. But I see that everyone, nearly all Congolese, are concerned by mental health problems in some way. Its a service thats neglected across the country. A lot of people display \[aggressive\] behaviour that, to the untrained eye, wont be seen as psychologically abnormal. But if services were multiplied all over to help people, perhaps aggressive behaviour and other problems would diminish, and there would be less violence in the community.

Back at the displaced persons camp in Mweso, the play is halfway through its three\-hour run and a distressing scene is taking place. The daughter of the neglectful father is out collecting firewood, when she is approached by two armed men. They chase her through the woods, catch her and hold her down. What follows isn't shown, but many people in the audience know what comes next. Some wipe tears from their cheeks.

> **Not everyone accepts the idea that people can be cured with words**

Sometimes, people cry when we tackle things they have experienced in their own life, says Sifa Clementine. In mental healthcare, when it comes to tears, they are a very good thing. Since they experienced these problems they may not have had time to cry. It is through tears you can relieve yourself. Traumatised, the daughter returns home. The next day, an MSF outreach worker comes to her village to promote the services MSF provides, including counselling for survivors of sexual violence. With the help of her mother, the daughter makes her way to Mweso hospital to talk with an MSF doctor and psychosocial counsellor.

As Sifa says: Not everyone accepts the idea that people can be cured with words. "But I will always say to people that there is no health without mental health.

> [**Find out more about MSF's work with mental health around the world >**](\-health)

Tumaco, Colombia

Our team in Tumaco is helping residents who have been suffering the psychological effects of violence for over 50 years. Click 'Enter' below to find out more.

Colombia: The invisible wounds of Tumaco

Healing the hidden wounds of Tumaco

Providing mental health services in response to urban conflict in Tumaco, Colombia

KickerThis is a kicker.

> MSF has been working with communities ravaged by violence in Colombia for many years, caring for the psychological wounds of people living amid violence and fear.

Tumaco is a city of 200,000 people in the Nario department in south\-west Colombia, near the border with Ecuador. Its location and thriving port have made it a hot spot for the trafficking of illegal arms and drugs. For 15 years, the Colombian army, the leftist Revolutionary Armed Forces of Colombia \(FARC\) movement, paramilitary groups and drug cartels fought for control of the territory. The conflict has left the city devastated and its people traumatised.

Amidst this violence, those who suffered most were local communities. The violence has claimed more than 80,000 lives in the past 50 years. Levels of violence have dropped since the government and the FARC movement signed a peace accord in 2016. However, violence is still endemic and has become more chaotic as criminal gangs move in to fill the vacuum left by the FARC. Poverty, high unemployment and a sense that crimes can be committed with impunity fuel the continuing violence. While the conflict is mainly between armed groups, it is the people of Tumaco who have borne the brunt of the violence. The pervasive sense of fear and insecurity it creates have had a devastating impact on peoples health. They have suffered threats, extortion, displacement, injury, torture, sexual violence, forced recruitment and other abuses, and have seen family and friends lose their lives. This has led to high levels of anxiety, depression and other mental health problems.

MSF in Tumaco

MSF began providing primary healthcare services in Nario in 2010, and started offering mental health services in urban areas of Tumaco in 2014, following a surge in urban and sexual and gender\-based violence \(SGBV\). The pervasive violence in Tumaco had a brutal impact on the physical and mental health of its people.

Our primary goal is to provide comprehensive medical care, including mental healthcare, to victims of violence, in particular to survivors of sexual and gender\-based violence. Our team in Tumaco provide individual counselling and group sessions, as well as working to raise awareness about mental health issues among the local community.

By providing the community with free, high\-quality mental healthcare, MSF has helped the wider community recover from the violence of both past and current conflicts. Our team is made up of 11 psychologists, two medics and four mental health promoters.

Igniting La Negra Ardiente

MSF is there to help the people of Tumaco survive their darkest moments. With the support of an MSF psychologist, a woman known as La Negra Ardiente the Burning Black has walked through the darkness and emerged as a strong and inspirational figure.

Her history is one of conflict and trauma. La Negra Ardiente was born near Tumaco, in an area that deteriorated as conflict consumed the region. As an adult she was beaten, abused and raped. She suffered severe depression and suicidal thoughts.

> **"After the armed conflict arrived, \[life\] became very stressful. You always lived in fear. There were always grenades going, _boom_, _boom_. It became unbearable to be here."**

But through workshops and one\-to\-one counselling with an MSF psychologist, she was able to put the traumas of her past behind her. Inspired by the play of light from vigil candles, she adopted her new name, 'La Negra Ardiente' to honour this.

La Negra Ardiente is now a community leader, watching out and supporting her neighbours, who she refers to as her family. She is dedicated to helping other people.

> **"I try to contribute something good to the family. We are training young people, children, adolescents. Teaching them dance, teaching them how to sing \- to dilute, to lessen the fear."**

Rebuilding lives: Betty's story

"My emotional problems began one morning. I was at my sister\-in\-laws house and at that exact moment my brother\-in\-law was murdered in the house. From that moment, my life completely changed." Bettys husband was the one who came looking for help. After hearing about the services that MSF provided, he arrived at the clinic one morning in August 2016, extremely distressed. If MSF didnt help Betty, he said, he didnt not know what he would do. Betty began counselling sessions with Dr Yeni, an MSF psychologist, soon after.

> **Betty was diagnosed with post\-traumatic stress disorder \(PTSD\). Seeing her brother\-in\-law murdered had triggered a psychotic depression.**

When she first began to receive help from MSF, Betty didnt know where she was or what day it was. She had not left her room in days. She cried constantly and didnt eat. She was about to lose her job, and could no longer take public transport because she was afraid that people would harm her.

Through her sessions with Dr Yeni, Betty's learned to understand and control these feelings. The psychologist gave her tips on how to control her emotions and her negative thoughts. "Now I feel much better, thank God, because I am living my normal life again. I can walk alone. I feel that things have improved from that time to now."

With the community: Elva's story

As a community leader and womens rights activist, Elva Gonzalez has dedicated her life to helping others. She did this even at the expense of her own mental health, as her role exposed her to suffering as well as threats and abuse. She lost many friends and colleagues to the violence that has ravaged the streets of Tumaco for so many years.

> **Many have died working for the community. People who wanted their community to change, to have a different future, to better their knowledge.**

Elva lives in the _Once de Noviembre_ neighbourhood of Tumaco, an area previously controlled by paramilitary groups who ruled peoples lives and killed with impunity.

Those were terrible days, they were filled with sad, painful moments, where women lost their husbands and children at the same time. Some families had their children and grandchildren killed at the same time. Elvas exposure to so much suffering began to affect her own wellbeing.

> **I did not sleep at night. I thought that when I heard something like a stone fall, it was a grenade.**

Elva received counselling from MSF, which helped her come to terms with her experiences and regain her mental and physical health.

I thank God for MSF arriving. When you talk, you unload those things that pinch you inside the stomach. And when you recount your life, some of those bad energies that are in your body come out.

Mental health problems can have a profound impact on people and communities. People experiencing these conditions can feel less able to function within their families or as part of society. When treating mental health conditions, MSF teams focus on understanding the social, political, economic, spiritual, cultural and moral points of view of our patients. Our approach targets the individual and community factors that influence mental health.

[**Find out more about MSF's work with mental health around the world >**](\-health)

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Our response to mental health

Depression and anxiety

People who have lived through crises can be immobilised by depression and anxiety, at just the time when they need to take action for themselves and their families.

Mental healthcare is also part of services for HIV/AIDS, tuberculosis, nutrition, sexual violence and during disease outbreaks and disasters.

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MSF’s mental healthcare aims primarily to reduce people’s symptoms and improve their ability to function. Often this work is done by local counsellors specially trained by MSF. MSF psychologists or psychiatrists provide technical support and clinical supervision.

When appropriate, MSF’s counselling services may reinforce or complement mental healthcare approaches that already exist in the local community.

At the same time, specialised clinicians treat severe mental illness. But severe illness accounts for a minority of the cases that MSF sees.

Needs are high, and MSF continues to expand its mental health programs. Last year, MSF’s mental health teams performed more than 100,000 consultations worldwide.

Increasing capacity

People sought help for many reasons — the agonising loss of a child in an earthquake, the trauma of sexual violence, getting caught up in a violent conflict. MSF mental health workers listened to their stories, and helped them find ways to cope and move on with their lives.

Treating severely disturbed people remains a challenge for MSF teams, given the complexity of managing psychiatric drugs and medication.

Increasing teams’ capacity to treat these illnesses remains a priority for MSF.

Setting up mental health care programmes in emergency situations is not straightforward, especially when violence and trauma is ongoing and no ‘cure’ is therefore possible.

Sometimes it is difficult to guarantee continuity of care in unstable and dangerous settings.

This page was last updated on 10 October 2017.

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