Aid groups adapt Rohingya mental health services for population in limbo

BANGKOK — In sprawling camps that dot Bangladesh’s southern coast, nearly 1 million Rohingya refugees spend each day in limbo. Questions about what their future holds have intensified in recent weeks as Bangladesh and Myanmar negotiate the tense push and pull of repatriation.

In mid-November, Bangladeshi officials arrived at Unchiprang camp in Cox’s Bazar with buses, ready to begin the repatriation process by transporting a preapproved list of refugees to transit camps on the border. Not one refugee volunteered to repatriate. Instead, groups gathered to stress they would only return to Myanmar once certain conditions — including security from violence, basic rights, and citizenship — were granted by the Myanmar government.

The repatriation exercise only served to further upset an already deeply distressed population, several mental health experts working in the camps told Devex. In the lead-up, some Rohingya fled their shelters for fear of being forced to return to Myanmar, and others were unwilling to accept any humanitarian aid services at all, worried that it would link them to the repatriation process, according to the response’s Inter Sector Coordination Group November report.

Aid groups have been providing mental health support since more than 700,000 Rohingya fled a Myanmar military crackdown in August 2017, carrying with them harrowing tales of rape, murder, and arson as they took shelter with the estimated 200,000 refugees already in Bangladesh.

“In the beginning, it was a lot of acute reactions to things that someone had just experienced, like ‘I was sexually assaulted,’ or ‘my loved ones just died,’” said Jodi Nelan, mental health activities manager for Médecins Sans Frontières’ response in Kutupalong and Balukhali camps.

“And now it's sort of a bit of a mix of difficulty coping with what's gone on in the past along with difficulty coping with how their life has changed and what they're experiencing on a day-to-day basis.”

MSF’s services have remained largely the same since the initial refugee influx, but “what has changed is what's actually happening in the counseling sessions, because the needs of the people have changed,” Nelan said. Aid groups are now working to adapt services to better serve refugees stuck in a toxic state of limbo — providing continued education about psychosocial support, holding one-on-one and group counseling sessions, and integrating efforts to monitor children for signs of distress.

New to mental health

Few Rohingya were familiar with mental health services prior to entering the camps. And in a study conducted in February by the International Organization for Migration, 48 percent of refugees surveyed throughout three camps said they didn’t have any idea about mental health and psychosocial services available, particularly related to stress-relieving activities.

“Lack of knowledge [about mental health] is a challenge,” said Nelan, who tries to stress the point that counseling should ideally be stretched over several sessions rather than conducted via a one-time crisis intervention.

MSF has prioritized psychosocial education on top of the one-on-one and group counseling services it provides at two clinics in the camps. Many of the sessions’ attendees first seek treatment by a doctor but are referred to the mental health team when it turns out their chronic symptoms are caused by stress.

Counselors who provide cognitive-behavioral therapy or relaxation methods are working to make sessions as comfortable as possible so that people will return. The MSF team recently began sharing messaging about what confidentiality means, for instance, since it was a concept previously alarming to Rohingya who equated it with negative connotations of secret keeping.

Save the Children, which counts about 35 psychosocial professionals throughout 10 health facilities in the area, has focused its efforts on providing group talks to help parents identify symptoms they might see in their children — such as clinginess, aggression, or trouble sleeping — and determine what they could mean and when to seek help.

“Parents might think, ‘my kid is acting funny, maybe there's something wrong with their head,’ when actually, if they understand that these are symptoms of psychosocial distress, then they might be better equipped to provide their children with the support they need to recover,” said Daphnee Cook, Save the Children’s communications and media manager for the Rohingya response.

An integrated approach with Save the Children’s child-friendly spaces — areas where children can play safely while their parents tend to other daily necessities — allows the NGO’s child protection staff to monitor behavior and identify children with signs of ongoing distress, including being overly withdrawn or disruptive. Staff might then refer the child to a case manager in order to set up a counseling session.

Still, it’s hard to prioritize mental health counseling sessions when refugees must also regularly queue to receive food aid or travel long distances in the hilly camps to collect drinking water. For women especially, who juggle many responsibilities in the home, “to take the time and to come for counseling, or to focus on themselves, can be a challenge,” Nelan said.

What’s next?

Groups providing mental health services for such a large population are still busy training their teams and adapting their services. International NGO Humanity & Inclusion was present in the camps prior to the overwhelming refugee influx that began in August 2017, but it has taken time to recruit counselors who speak a similar language to Rohingya and to build up their knowledge to serve the population, said Gilles Nouzies, Asia desk manager at Humanity & Inclusion, which focuses its mental health support on people with disabilities and vulnerable populations.

“Of course there’s a language barrier, so it’s not possible for an international [counselor] to provide these kinds of services,” Nouzies said of psychosocial support. “It’s all about training, and training, and training again, because of course it’s new for the majority of our staff, so they have to learn and practice immediately.”

MSF’s Nelan works to monitor the international NGO’s mental health team and see where more training might be useful, but she credits the Bangladeshi staff MSF has hired with quick learning and natural compassion. Much of counseling revolves around someone feeling comfortable sharing worry or stress with a counselor they feel is kind, nonjudgmental, and willing to listen to their story.  

“So on one hand, learning the technical stuff has taken time, but learning how to build a relationship and how to just kind of be with someone, and show compassion? All of that has been really easy [for our staff],” she said.

Nelan is hopeful about improvements she’s seeing in attendance of sessions as a result, noting that people who have been to counseling and found it effective are starting to bring family or neighbors with them the next time they attend.  

Initially, refugees were coming without knowing exactly what to expect from a one-on-one or group discussion, and many believed that “just talking” couldn’t help them, according to Humanity & Inclusion’s Nouzies. But through their exchanges with other refugees, they understand that what they’re going through is a shared experience, and they can also share solutions and learn from each other, he said.

“Even though initially people might think ‘it’s not useful,’ or ‘it’s just talking,’ I think most of them quickly understand the benefit they can get from these discussions,” Nouzies added.

Humanity & Inclusion is in the process of switching from door-to-door counseling services to more sustainable, clinic-based services in the coming months, acknowledging that there is no end in sight to the needs of stateless Rohingya taking refuge in Bangladesh’s camps.

“Now that the camps are organized, the people feel safer than before because they have somewhere to stay,” Nouzies said.

“They have access to food, access to health care. But now the question for them is: What’s next? That’s true for all refugees worldwide. What is going to happen to us in one month, in six months, in one year?”