Psychiatry in post-conflict settings in low-income countries

Floor van Dijk
 

Introduction

The destroying effects of war and mass violence are generally acknowledged. Countless organizations come into action to rebuild societies in regions ruined by conflicts and to provide basic healthcare. But amidst the chaos of hunger, loss of family members and households, societies get wrenched and people are individually put under great mental pressure. The result is a severely increased risk of developing psychological and psychiatric disorders, for which psychosocial healthcare is of great importance. In the Western world, the mental health care system is well developed and it seems ready to be used for those thousands of traumatized refugees in camps in low-income countries. However, psychiatry is by definition a specialism that is sensitive to cultural differences. This cultural gap results in clinical implications. For example, how should the Western psychiatrist deal with the supposed depression or general anxiety disorder of a Congolese mother whereas the woman only complains about her heart wanting to fly out of her chest?

Democratic Republic of Congo
The conflict in East-Congo is rooted in the Rwandese genocide in 1994. Loose clusters of rebels and militants of the Congolese government are fighting a war to gain control over the country, which is rich in natural resources.
Without an overall strategy or central commando, in general these groups of militants are undisciplined and violent. Local warlords have enriched themselves upon the export of diamonds, wood and minerals and use their militants mainly to preserve their privileges by plundering and burning villages of local people while destroying crops. Most of all, these groups of rebels are feared for their reputation as rapists and recruiters of child soldiers.
Rape is a common inducer of a trauma-related mental disorder. A raped woman is often blamed for what has overcome her, thereby losing her honour and social support of family members. If she dares to talk about what happened, the risk of marginalization is very high. To avoid this, many women decide to flee from their communities. The loss of a social background adds up to the damage done by the raping.
 

A culturally dependent expression of trauma

Underneath a greatly varying presentation of psychiatric disorders in different cultures lie a few universal mechanisms. One of these is the physical reaction to stress and traumatic experiences, such as mass violence during war. A stress reaction leads to an increased stimulation of the sympathetic system, which causes sleep disturbances, an increased startle response to sounds and changes in the circulation of endogen opioids and adrenergic hormones.

However, the degree and the way in which the traumatic effect is expressed is both individually and culturally bound. Beliefs about individual identity and characteristics of one’s community determine how someone gives a meaning to loss of a family member or experiencing atrocities. Non-western cultures, often referred to as traditional, are more likely to have a collectivistic way of living and of regarding social relationships. In these traditional cultures people maintain strong ties to family relationships and are more bound to social roles. Religion and tradition explain the way mind, body and the higher spirits such as ancestors, gods and natural forces are connected. Additinonally, one’s individual thoughts and feelings are of less importance than the well-being of the community. Mental distress is mostly expressed in physical symptoms rather than in emotional complaints. Furthermore, disabilities are expressed in the context of the social role instead of the personal changes in one’s character, like we are used to in our individualistic, Western society.

Difficulties in diagnostics and treatment

The diagnosis of mental problems such as depression and anxiety disorders can be complicated. Clinical presentation is diverse, because organic factors often play a smaller role than various psychological influences and social background. Furthermore the DSM-IV uses a very Western approach. This makes it difficult to recognise physical complaints, like having a thrilling tongue, as a symptom of depression. The existing pile of questionnaires is nonetheless mostly based on criteria found in the DSM-IV and ICD-10. Their validity often depends on the background of the patient. For example, a study of Fox (2003) shows that West African traumatized patients responded only partially to the Hopkins Symptom Checklist (HSCL-25). The rest of their complaints could not be identified with this diagnostic instrument. Unfortunately, no universally applicable questionnaire has yet been validated. Furthermore, in Western psychiatry it’s quite common to let the patient fill in a self-report questionnaire. However, people from a less stable society torn apart by years of war, sometimes are afraid of writing down their story, suspecting it will be used against them. Diagnostic interviews are the solution, but require good knowledge of the local language and medical idiom.

Secondly, the stigma on mental disorders has far-reaching consequences. Especially in a lot of African societies, psychiatry is associated with the mad. In these countries psychiatric patients often have been isolated from communities for years, living an abominable, errant life. It is therefore important to try to avoid this label when treating someone in a psychiatric setting. An individual approach has proven to be less effective in non-Western patients, since they appeal to a patient’s personal coping strategies rather than to social mechanisms. The latter are more important in patients from a collectivistic society.

Since disruption of social and family networks is one of the most important causes of the traumatic effect of war, group therapy builds on restoring these social coping mechanisms. It also provides the opportunity to include traditional ways of expression of emotions, such as traditional dance or elements of a ceremony. Besides, group therapy is a way to reach more patients at once, which can be crucial in a refugee camp where thousands of people are in need of mental health care. For example, de Jong et al (2000) found a prevalence of 50% of psychiatric disorders in Burundian and Rwandan refugees.

Practicing post-conflict psychiatry

Concluding, the role of Western psychiatry consists of different aspects. Besides cultural differences, mental health workers encounter organizational problems. This led to the framing of the International Guidelines on Mental Health and Psychosocial Support in Emergency settings, set up in 2007 by the Inter-Agency Standing Comittee (IASC). These guidelines offer the possibility to evaluate and improve the coordination of mental health care and different psychiatric practices.

According to the triangle of intervention, the process of developing a mental disorder as a result of trauma is cumulative. The experience of a traumatic event itself is a risk factor, just as the breaking of social and familial structures and the lack of shelter and safety. Part of the treatment is preventing development. Mental health care therefore is strongly connected to post-conflict human care in general. After basic needs such as safety, shelter and food are provided, social structures need to be restored. The top of the triangle is aimed at specific psychiatric and psychological treatment.

The IASC guidelines show that mental health care is part of an extensive area of human care in post-conflict situations. To achieve good mental health care, more education about the aetiology of mental disorders is needed and organizational problems should be solved. Furthermore, our Western psychiatrist will never be able to help the Congolese mother on his own. Local health care workers are needed in the cultural approach in order to develop diagnostic interviews and therapies.

This is essential for the acknowledgement of outflying heart of the Congolese mother. It might help her to let her heart fly back.

About the author

Floor van Dijk is a fourth year medical student from the University of Amsterdam. This article is based on her paper in which she won the Wout Klein Haneveld prize of the NVMP (Dutch association for medical polemology).

Further reading

• Jong, de, JP, Scholte WF, Koeter MW, Hart AA. The prevalence of mental health problems in Rwandan and Burundese refugee camps. Acta Psychiatr Scand 102, 2000
• Jong, de, J.T.V.M, Komproe, I, van Ommeren, M. Common mental disorders in post-conflict settings. The Lancet, vol 361, 2003
• Fox, S.H. The Mandinka nosological System in the context of post-trauma syndromes. Transcultural Psychiatry Vol 40 (4)
• IASC, Guidelines on Mental Health and Psychosocial Support in Emergency Settings. Inter-Agency Standing Committee, Geneva: 2007

Photo by Robert Marin, shared under Creative Common License, edited by GM
Photo by Kris Krüg/usarmy, shared under Creative Common License, edited by GM