Psychological support for patients in distress
October 23, 2013
Syria is in the grips of extreme violence. Patients, families, health workers… no one is spared and anyone can be in need of psychological support. MSF psychologist Charlotte spent three months in the country listening to what her patients had to say.
At the hospital in the Aleppo region I didn’t just see patients but their friends and families too because they were in almost as much need of psychological support as the patients themselves. What these people are enduring makes them vulnerable and fearful. In a state of acute distress and pinning a lot of hope in the treatment, they are looking for a miracle and their unrealistic expectations often leave them disappointed.
Among the patients and their support networks, I saw many very anxious and depressed people. Syrian and international care providers are completely overwhelmed by requests for help. People have nowhere to live, nothing to eat, no money to pay to get to hospital for their treatment and sometimes no family left to support them or a school for their children to go to. They see no future and are racked with anxiety... They’re not only concerned for themselves but also for what the future holds for Syria.
The distress of patients who have suffered injuries and find themselves disabled is all too apparent. Accepting disability is grim for people who have been paralysed, or disfigured, or amputated because of injuries or burns inflicted on them in an explosion.
Disfigurement is particularly harrowing, as disfigured girls of marrying age will never be able to find a husband.
11 year-old D. suffered severe burns to her face and upper body. Only her legs were left unscathed. Her injuries were already old by the time she arrived at the hospital. She hadn’t been able to get treatment any sooner as field hospitals only provide care for the war-wounded and most other hospitals have either been destroyed or have insufficient personnel and drugs.
D.’s burn injuries were caused by a fuel cooking stove that exploded, a common occurrence as fuel is of very poor quality and often explodes. The effects of the burns were horrific and the little girl couldn’t shut her right eye or her mouth. Her head appeared to hang down and had stuck to her neck because the skin had retracted as it healed. She needed an operation. The surgeon made an incision in her neck so that she could hold her head up. And then started the dressings and the skin grafts…
The other patients and their families kept asking us: “Will she get a normal face back?” “She’s going to have to get married one day,” they would explain. But sadly, the little girl is disfigured for life.
The all too visible distress stems from people’s feelings of insecurity and their incertitude about the future. And there’s the fear of the shelling. People are scared to move around on roads where they are forced to go through checkpoints held by armed men, making it increasingly difficult to get from one place to another. How many times did I hear men and women say: “If I can’t cultivate my land, if I can’t sell my produce, what’s going to become of me?“
And beyond this distress, emerges a generation of disabled people, bringing with it its own problems of mobility, resources, social integration, and so on.
Syrian and MSF personnel also need support
I worked with a Syrian psychologist who sees all the hospital’s patients and is responsible for their treatment. She started working two weeks before I arrived [Charlotte’s mission began in mid-April]. She’s the one who’s there when a patient has to be told: “Your wife is not going to live.” Her support is invaluable.
She gets on well with MSF’s Syrian personnel who also turn to her for help because they face the same problems as their patients and need support too. Death, loss and suffering, as much physical as psychological, are as integral to their everyday lives at the hospital as they are to their patients’. Then they have to go home to their own families and communities and confront the same death, loss and suffering all over again. The cases they see over and over reflect their own sorrows, and it’s hard for them to keep the perspective they so badly need.
I set up discussion groups, particularly for our interpreters. They have the gruelling task of listening all day long to the traumatic stories told by patients and then having to repeat them as they translate them. They have to translate all exchanges with international MSF staff working in the hospital so they hear and see a lot, they are in the operating theatre, they’re with the patients, they’re everywhere. They aren’t trained for it and they really get hit hard. I’m trained, it’s my job, and it gets to me. So for them…. It’s not the same for the doctors and nurses who have their own coping mechanisms. But it can be complicated for them too, especially when really little kids are involved, as there’s a huge emotional impact that’s difficult to cope with.
Close ties within families and the community
What is really striking is the tremendous solidarity within communities and families. When people are hungry, they can go to their neighbours who’ll share the little they’ve got and give them something to eat. I remember the case of a young woman with severe burns who needed somebody to be with her at the hospital to help her eat and wash. Her mother had other teenage children who needed her so she couldn’t be away from home for the long weeks or even months burn patients have to stay in hospital. But her neighbour had older and more independent children and immediately offered to help when she found out what had happened, even though she didn’t know the mother very well at all. She stayed with the daughter day and night for four weeks, in fact right up until she died from her horrific injuries, and then went home.
The little girl who didn’t want to talk
Among the patients needing psychological support there were many children who had been uprooted after being forced to flee their homes with their families. These young patients had been wounded or had witnessed terrible violence, like a little six-year-old girl that MSF psychologist Charlotte was able to engage with.
There was a six-year-old little girl who, since she saw her brother torn apart by a bomb, had become almost completely silent. She would draw lots of pictures with loads of bright colours but they were quite basic compared to what other children of her age can do. She used the splurges of colour with no visible human shape to conjure up the image of the terrible thing that had happened to her brother. They represented something specific that I tried to understand through a question and answer game, sort of riddles, in order to secure our therapeutic relationship.
She was quite happy to let me into her world, but in her own time, so I had to move forward very slowly and respect the immense suffering expressed in her drawings. She would answer my questions about her pictures with a nod of the head and sometimes with laconic words spoken so softly I had difficulty in hearing them. She would press on her pens so hard that the paper would tear and it looked to me that her fierce colouring of the vague shapes allowed her to empty her head and the feelings she had deep inside.
A the end of each session, she was quite happy to give me her picture, to leave it with me, as if this was a way for her to lighten the suffering she had cast aside in it. But she wanted something to take away in exchange, a small toy, a trinket... maybe to fill the gap that was eating away at her, or maybe because ours really was a relationship of sharing and give-and-take! During our sessions she would offer up her anguish like a gift, a difficult and painful process that she needed encouragement with. And at the age of only six, it took real courage...
This was several months ago now and her mother is alive and with her. The little girl has no physical injuries, but her wounds are invisible and ever-present.
How a kind lady racoon helps a kid racoon
To establish a dialogue with the little girl and her other young patients, MSF psychologist Charlotte used a picture book that tells a story based on racoons.
I used a book that really helped my work with the children. It tells the story of a little racoon who is traumatised by something awful and frightening without actually specifying what the awful and frightening thing is so as to be universally applicable. As the story unfolds, the book uses wonderful illustrations to depict the everyday consequences of a traumatic experience.
So, the kid racoon doesn’t understand the awful thing that has happened to him. He doesn’t feel right and does his best to forget it. And he manages for a while but then feels bad again. He loses his appetite, he has a tummy ache, he feels sad and anxious for no apparent reason and does everything to excess – he runs too fast, he sings too loud… to forget what’s weighing on him. He can’t get to sleep and when he does, he has nightmares. It makes him angry and he starts having problems at school, he’s naughty and often gets punished, making him even sadder. He’s bewildered and he doesn’t understand what’s happening to him.
Luckily his parents take him to see a kind lady racoon who listens to him attentively. Sometimes grown-up racoons really know how to get kid racoons to talk about their complicated thoughts and emotions! While he’s with the kind lady racoon, he plays, he talks and he draws, which helps him find a way out of his confused emotions. She asks him to explain his drawings and reassures him by saying that the awful thing that he saw wasn’t his fault and then she praises him because she knows it’s hard to talk about all the things gnawing away at him. He starts to feel better, stronger, less angry, he sleeps well and doesn’t really have tummy aches anymore. He hasn’t forgotten the awful thing he saw, but he no longer thinks about it all the time.
The illustrations in the book are delightful and very straightforward, so although the text is in English, the story is really easy to understand, even for children who can’t read. All I had to do was change the kid racoon’s English name to an Arabic one, Ahmed.
I gave the book to the little six-year-old who had seen her brother blown up. The interpreter and I told her the story and showed her the pictures. At the end, I asked her which pages she liked best. She first showed me a picture of the racoon with his eyes wide open and who can’t get to sleep. The second picture she liked best was the one where the racoon is gripping his tummy because it aches so much. And then the one where he’s drawing pictures in the kind lady racoon’s consulting room, and lastly, the one where he’s stretching out in the sun after a good night’s sleep. Naturally, she wanted to take the book away with her at the end of the session, and I was delighted to give it to her. I told her to read it with her mother and father! The pictures really helped her along the road to accepting what had happened to her, and we read the book several times during our sessions.
Tools like these are incredibly useful and easily accessible. All the children I shared the book with found it easy to identify with what happens to Ahmed and were able to better understand the emotions that overwhelmed them and prevented them from being the children they are.
When language is no longer a barrier
MSF psychologist Charlotte does not speak Arabic so an interpreter assisted her in her conversations with her patients. Except on one occasion, when Charlotte used French to talk to a small baby.
S. was only five months-old, the daughter of a fairly poor family who decided to leave their village after it was bombed several times. As they arrived in a neighbouring village, a bomb fell on their car. All the passengers, her father, mother and three of her eleven brothers and sisters, were killed outright, but she survived. Her leg was torn off and she had to be amputated at the thigh. One of her older sisters now looks after her. Aged 19 and wounded in the foot during a rocket attack, she has her own 8 month-old baby. So she’s now looking after both babies and also breastfeeds S. The solidarity at the hospital was amazing. For example, when her older sister was too exhausted to feed S., the other women on the ward did it for her. The baby soon became the hospital mascot!
I had a real connection with this little girl. The hospital medical staff told me her story before I met her and said that she cried a lot of the time – perhaps because of the phantom pain caused by her amputated leg.
When I saw her for the first time, I took her in my arms to establish a physical contact and, speaking in French, told her what had happened to her. She listened very carefully and it felt as if her eyes were piercing me, that she was looking right into my soul. It was a highly charged and very special moment. All the women around us were also listening to my words, spoken in a language that was totally foreign to them, not able to understand, but grasping the meaning, just like S.
So I looked her in the eye and held her – more supported her – in my arms and stroked her face. I wanted to tell her her story, put into words the terrible things she had been through. So I told her she really hadn’t been lucky, that she had had a really sad experience and that she wasn’t going to see her parents again. That she must have been absolutely terrified, that she must have heard a huge bang and felt the intense heat and seen the flames. And I told her that she couldn’t possibly have understood what was happening. I said it wasn’t her fault and that she was going to have to be really brave. She understood my intonation, she felt supported and she glimpsed an expression of reassurance when I said that we understood her, that we knew she must still be terribly frightened.
Then she answered me. She really spoke to me; she said something. It was a kind of communication, a dialogue between her and me. I talked to her again and she answered me. I told her she had lots of things to say. This went on for several minutes while the women watched us in amazement. Soothed by the stroking, she fell asleep. She slept peacefully for a good five minutes and then became agitated. All of a sudden, she really flinched and the expression on her face was awful. Maybe she was reliving the explosion? When she woke up, she scrutinised me again with her piecing look, and then started to gurgle.
I saw her regularly; I never missed an opportunity to see her. She was the hospital’s favourite and was passed from one person’s arms to the next. I remember a particularly moving moment when a wounded patient (and a hardened fighter) took her in his arms and spoke some very pretty words to her in Arabic that meant, “you’re this hospital’s little treasure”.
Then one day I gave her a teddy bear and she was so excited. There aren’t any toys in the hospital and it’s tough for the children. They’re in pain, they cry, they need their mothers. When they see a nurse or a doctor, they think there’s going to be more pain, they’re scared because the treatment isn’t easy. S. looked at me with her inscrutable eyes, and then at the teddy and smiled. She grabbed its big ears and hugged it so tight that her fingers turned white. Then she put it to her mouth like babies do, with a look both questioning and enchanted, as if to say, “What’s this, a toy? Is it mine?” She played with it for 15 minutes or so, a very long time for a child her age as they don’t usually stay focused on anything for more than five to ten minutes.
When she left the hospital, she went to live with her 19 year-old sister and relatives in a house meant for ten people but by then had twenty to thirty people living in it. S. has returned to the hospital from time to time for her dressings to be changed and physiotherapy. The Syrian psychologist has been able to see her since I left.
And what will happen to her now? How is she going to learn to walk? How are her family going to be able to buy the prostheses she’s going to need? And as she grows, she’ll need different sizes.