An overlooked part of the Nepal quake response: Mental health

It is just over two months since the first earthquake hit Nepal, which killed almost 9,000 people and demolished more than 500,000 homes. Thousands of aid workers descended on the poor, landlocked country before yet another earthquake hit and shook the Nepalese again to the bone. Experts, wary that survivors would be traumatized, warned of an impending mental health disaster if people’s needs were not met. Despite this, few nongovernmental organizations actually address the mental toll of disasters — mental health is seen more difficult to treat than physical wounds and not sexy enough to receive the funding it deserves. But months on and just as the monsoon season begins, hundreds of thousands of Nepalese are still living in makeshift tents across the country. While some have been forced to do so because their homes were destroyed, others are simply too scared to sleep indoors. Martha Bragin, associate professor at the Silberman School of Social Work at Hunter College, who has had considerable experience in Nepal, told Devex there were three reasons why people were still sleeping outside: They could be ill-informed and perhaps had heard rumors that it wasn’t safe inside, they are well-informed but foreign aid workers have made them feel inferior and confused, or people were fearful of being ignored and missing out on receiving aid. “People stay together outside to draw strength and comfort,” Bragin said. “Nepalis tend to be quite communal and people do better among a community in times of disaster. From what I’ve heard, people still don’t feel like it’s done.” ‘An opportunity to change things’ There is no mental health act in Nepal as its National Mental Health Policy is yet to be fully operational. The country has fewer than two psychiatrists per million people and even fewer psychologists, while mental health services are limited to a few hospitals in larger cities. Despite this, some experts here say the earthquake could present an opportunity for Nepal to provide better mental health services. Many people for instance believe mental health problems were a result of inner weakness. “While the earthquake was not a good thing, it could have a positive impact on the way people view mental health,” Nepali psychiatrist Dr. Rishav Koirala said. “Never have the Nepalese people been so united. It’s time for mental health to be uplifted, to take this as an opportunity to change things.” And Bragin agrees. “People have thought for a long time that Nepal doesn’t have a proper system for the mentally ill. It’s time to think about developing a more adequate system,” she said. “This should not be an opportunity though to develop one that increases stigma by isolating people in hospitals and giving special treatment to people.” Still, Koirala is concerned that “large populations of people are not getting the services they need. There is a lack of manpower and resources.” Psychological first aid So what can be done to lead to concrete change? According to a review of mental health and psychosocial well-being in Nepal by the Inter-Agency Standing Committee reference group for mental health and psychosocial support in emergency settings, several barriers prevent the delivery of mental health services in Nepal, including insufficient resources, inadequate number of mental health organizations and weak referral pathways. The review said training was a necessary component to bridge the treatment gap and stressed that some organizations had opted to train nonprofessionals in mental health skills to fill the gap. “The fact that most funding for NGOs is project-based limits central funding for contingency planning in disaster response. This lack of NGO emphasis in turn reduces government focus and role in contingency planning, as the focus of the two sectors are interconnected in mental health,” the review, published last month, noted. One way to address the lack of mental health workers is through “psychological first aid,” according to Dr. Brandon Kohrt, a psychiatrist from the Department of Psychiatry and Behavioral Sciences at Duke University in the U.S. Kohrt, who has 16 years’ experience working in Nepal, explained that PFA is increasingly used in post-disaster situations, including in Liberia and Sierra Leone following the Ebola outbreak. The evidence-based approach is designed to reduce initial distress and reduce the possible occurrence of post-traumatic stress disorder by providing humane and supportive help to people in the aftermath of a disaster. It’s a low-intensity, practical service that can be delivered by anyone involved with other aspects of humanitarian response, such as physical medical care, food delivery or education. The training can be completed in two days. “Psychological first aid has no forced structure of recounting trauma — it follows the lead of the person affected by the earthquake. It’s about listening and making them feel more secure. It’s not about asking them to tell [us] what happened during the earthquake but about empathetic listening,” he said. Kohrt estimates that up to 200 people had gone through the two-day training since the earthquake. The same approach was used to assist the victims of the country’s decadelong armed conflict between the government and Maoist rebels. “Local is always best but there’s lots of foreign NGOs around and they need something to do,” Bragin said. “It’s about simply checking in with people — asking their name, who they are, if there is family around, how they feel and how we can help. It’s about directing them kindly and supportively to whatever they might need.” Patients who need further care, meanwhile, could be referred to those who can provide diagnosis, treatment and individualized care. Cautious diagnosis Korht warned that while many earthquake survivors were dealing with nightmares, poor concentration, anxiety and other classic PTSD symptoms, it would be a serious mistake to label them with the disorder. “We don’t want to victimize and say that everyone affected by the earthquake is going to have a mental health problem. The vast majority of people recover and do well. We need to be very careful about not overlabeling people with PTSD and very cautious about using diagnosis because it has social implications,” he stressed. Koirala said that while he was seeing people present with acute stress disorder, which has similar symptoms of PTSD, he believes that most would, in time, recover. “I think most will recover by themselves. We need to utilize PFA because of the lack of manpower and try to get people to return back to their normal activities,” he said. But what can be done in a country like Nepal, which exists on fault lines, to ensure people feel safe? “Telling people they’re safe in this world is at best a lie,” Bragin said. “But most people live with unsafety without being distressed by it. People who experience the most severe types of unsafety are not crazy. Nepal exists along a fault line and those plates are moving. But things can be done: One can use finances to build buildings which can withstand earthquakes.” Kohrt agrees, adding that the aid community needs to be able to distinguish between people who are sleeping outside their houses because the structures are unsafe and those who do despite have sturdy buildings. “If the houses are decent then it’s a good sign that a person would benefit from some psychological support,” he concluded. Check out more insights and analysis for global development leaders like you, and sign up as an Executive Member to receive the information you need for your organization to thrive.