Psychological First Aid Provision for Urban Refugees in Uganda: Opportunities and Dilemmas
By Kampogo Mary Tumusiime and Yusrah Nagujja Kuteesa (Published 10th October 2016)
World Mental Health Day was first celebrated on 10th October 1992, nearly quarter of a century ago. This year the theme set by the World Health Organisation calls us to address the question of “Psychological first aid”.
Psychological First Aid refers to a range of natural, supportive and practical strategies used to reduce the painful range of emotions and responses experienced by people who are or have been exposed to high stress. Psychological first aid emphasizes listening without pressing the person to talk; assessing needs and concerns; ensuring that basic physical needs are met; providing or mobilizing social support, and providing essential information.
The reality that at least one in four adults will experience mental health difficulties at one time or the other has never been more pertinent than today when the world is struggling to understand and adequately respond to the highest numbers of forced migrants since World War II. As has been noted by Mark van Ommeren and Shekhar Saxena of the Department of Mental Health-WHO, “Brutal conflicts in numerous countries currently ravage the lives of more than 100 million women, men, girls and boys with more than 60 million people displaced”. (World Federation for mental Health: World Mental Health day 2016)
Crisis events, especially wars and conflict, expose wide masses to trauma and sudden loss and are to be found all over the world. The Great Lakes region of Africa is no exception. Uganda hosts the highest number of refugees in this region. According to the monthly statistics from Office of the Prime Minister (OPM), between January and May this year, the influx of refugees from surrounding countries including Democratic Republic of Congo (DRC), Burundi, Somalia and South Sudan increased from 18,223 to 64,937 refugees, a percentage increase of 7%. The total number of refugees in Uganda as of 5th September 2016 is 695,386. Of these, 83,092 reside in Kampala.
Many refugees have gone through multiple traumatic events that can easily compromise their ability to cope. At Refugee Law Project, for example, 1 in every 10 people who are screened at the Kampala office report severe mental health issues, while a further 5 in every 10 people report less severe mental health challenges. These include Post Traumatic Stress Disorder (PTSD), depression, general distress and anxiety. Only 4 out of 10 report no mental health issues.
For the majority of those with mental health issues, these can be traced back to torture and/or sexual violence.
The need for psychological first aid is increasingly evident; understanding is growing that people who go through traumatic experiences like war, accidents and other life threatening disasters suffer from psychological distress that often exceeds their usual ability to cope and to continue functioning normally. In the context of forced migration, psychological first aid becomes indispensable because most forced migrants go through multiple traumatic experiences that push them out of their familiar environment to seek safety in far lands that many have never known of.
During emergencies, people concentrate on meeting physiological needs like food, shelter and medication, and psychological needs are left barely attended to. While UNHCR and other refugee service organizations have tried to incorporate mental health services in their response to refugee problems, the need is still very huge. Although emotional distress is not always as visible as a physical injury, it is just as painful and incapacitating. This is more so for self-settled urban refugees who generally live without the humanitarian support that is channeled to formal refugee settlements.
For many asylum seekers in Kampala, after a long time of moving with heavy emotional burden from their flight experience, the first point of contact with the Ugandan authorities is Old Kampala police station where their statements and testimonies are recorded. The police officers may offer information about available services, listen to the concerns of the new arrivals and sometimes offer material assistance like food and accommodation for those who have no place to stay. From this point, they are referred to the Office of the Prime Minister to process identification as asylum seekers. OPM has a community service unit that may attend to cases of distress through talk therapy, listening, offering information and referral to other agencies or to the refugee settlements.
Refugee Law Project receives both new and old refugees. Refugees are received 4 days a week, Monday to Thursday and on average, 50 clients are seen per week. The first line of psychological first aid occurs at the reception, where clients are received and offered comfort as they wait to be assessed. In the intake and assessment office, they are taken through an assessment process that combines qualitative and quantitative data gathering about the issues being presented by the client. Frequently, as they narrate their concerns, they break down as they recall traumatic and difficult experiences they have undergone in their countries of origin and/or Uganda. The quantitative process involves using standardized tools to screen for experiences of SGBV, mental and psychosocial challenges as well as legal needs. At this point, the officers offer basic counseling to the client mainly offering comforting words and information about available services. This service at this point is very crucial as it involves helping the clients understand that what they are going through is a normal response to their past traumatic experiences and that they will eventually recover. For many, this explanation offers some relief, particularly when coupled with the assurance that they can always come and talk about their problems.
At that point, some whose needs do not fall under our mandate are referred or given information for services elsewhere. Those whose needs are within our mandate and ability to address are then referred to psychosocial, gender-based violence or legal officers for further action.
Those who are referred to legal aid may also show signs of psychological distress and legal officer often go beyond the legal issues to offer a listening ear. SGBV officers focus on the physical and protection needs of the clients with a combination of psychological first aid through talk therapy. Those who need psychological counseling are referred to the Mental Health and Psychosocial Wellbeing program.
RLP also uses other avenues to provide psychological first aid to urban refugees like support groups and peer counselors. Through more than 12 urban support groups initiated and mentored by RLP, refugees provide mutual support to each other and empower each other to cope and even move beyond their traumas.
Our experience shows that giving information on what mental health issues is an essential first step in enabling those directly or indirectly affected to identify mental health problems and seek help and/or link others for help.
Support groups provide useful platforms through which psychosocial needs of refugees are met. There are many instances of group members supporting one another in doing livelihood activities, which they would not have done alone. These groups also help a lot in reconstructing important social networks that many refugees lose, or in building alternative networks. Both can help to facilitate recovery.
Refugee Law Project, with funding from the Finish Refugee Council, trained 50 peer counselors of whom 25 are based in Kampala. The peer counselors have been trained in basic counseling skills and are approached by refugees in need of support; they can also identify those with symptoms of psychological problems, offer basic counseling, psycho-education and make referrals.
An example of psychological first aid care is with a woman refugee from DRC, who left Kyaka II refugee settlement coming to report her case of insecurity to OPM. She did not have permission to leave the settlement from the Camp Commandant so she reported that she could not be attended to by OPM. Someone directed her to the Refugee Law Project and on reaching the reception, she communicated that she felt her chest tightening and she collapsed. The receptionist let her lie on the floor; made sure she had sufficient air, checked for her pulse and alerted a counselor. The counselor called the ambulance but before it arrived, the client regained consciousness. The counselor let the client rest until she could communicate. She had not eaten for two days and asked to drink some milk. After taking milk that was offered, she was able to narrate her concerns to the counselor but still complained of chest pain. The counselor used “grounding techniques” and after 30 minutes it was clear that the client was not calming down. The counselor accompanied her to Kampala Capital City Authority Health Center IV in Kisenyi where she was taken through several medical tests. Her blood pressure had risen and she was found with a bacterial infection. She was given a bed for rest and further tests were done. After two hours, her blood pressure had normalized and she was discharged with prescriptions. The counselor helped her in the hospital by interpreting for her during her communication with the doctor. She was prescribed some medication although she did not have money to purchase it. The client reported facing insecurity in the refugee settlement, and she was advised by one of our lawyers to return to the settlement so that her case could be followed up by the RLP Hoima field office. Upon return to the office, the counselor gave her 15,000 UGX for transport and since she had nowhere to sleep, she returned to Old Kampala Police station where she spent the night. In the morning, she used this money to return to the refugee settlement.
In this case, the problem was both physical and psychological. She was concerned about her physical security and was also worried about food, where she would sleep, how she would go back home and about her children she had left in the settlement.
Cases like the one presented above are very common especially in the urban setting. Incidentally for most urban refugees, psychological first aid does not end as they continuously go through challenging situations of being evicted from houses due to failure to pay or seeing loved ones struggling with essential needs they are unable to meet due to lack of finances. This always undermines the progress of recovery as events trigger onset of distress and other mental health issues.
There are few psychological first aid providers compared to refugees in need of assistance. With a population of over eighty thousand refugees in Kampala and just a few refugee service agencies, many refugees are left grappling with their psychological pain. For example, the Refugee Law Project Kampala Office has 18 staff directly involved in attending to clients-compared to the 50 clients that report to the office per week with only 3 of these being mental health workers. Further, the majority of providers do not speak the multiple languages used by refugees in Uganda, hence creating a barrier for refugees to benefit from this support.
Many refugees have reported a lack of sensitivity and poor care as they are received and handled by service providers including refugee agencies, hospitals, schools, local councils to mention a few. Such scenarios usually result into worsening of the mental health concerns of the refugees.
- The Parliament of Uganda should amend the outdated Mental Treatment Act (1938) to ensure the rights of people affected by mental health issues are protected
- The Government of Uganda through Ministry of Health should pass the Mental Health Policy to put in place practical ways to guide programming and implementation of services geared towards provision of psychological services in Uganda
- Uganda’s Public Service Commission and Ministry of Health should amend its structure to create positions for psychologists and counselors who can attend to people with concerns in public hospitals
- The United Nations High Commission for Refugees (UNHCR) and other service providers should follow international guidelines like the IASC to ensure that psychological first aid is incorporated and implemented in all emergency situations and at all reception centers
- All refugee serving organizations should take an initiative to train their workers in basic psychological first aid skills to be able to attend to all refugees with the sensitivity needed of such context
- Donors should invest more in the mental health sector to ensure that more programs and more staff are available to meet the demands of those affected
- The general public should become more aware of their own mental health and that of those around them, so that they can identify, monitor, provide care and refer those in need for services
The writers, Kampogo Mary Tumusiime (Psychosocial Counsellor) and Yusrah Nagujja (Ag. Programme Manager Mental Health and Psychosocial Wellbeing) work at RLP.