181 192 Scholte-protocolo

This paper describes the conceptual framework andapplication of a working model (‘EPSoCare’) forpsychosocial intervention for refugees living in campsin low income countries. The intervention’s mainobjective is social re-integration of individuals withpsychosocial problems. The model was applied inpilot programmes in camps with survivors of the1994 genocide in Rwanda. The interventionsaimed to cover 360.000 refugees in camps inTanzania, and 230.000 in a camp in Zaire. The pilot programmes were heavily impacted by theprevalent insecurity in the camps and the atmos-phere of mistrust resulting from it, as well as by theinsufficiency of social services. The development ofpsycho-education material took more time thanexpected. Medical staff was not easily ready to betrained in psychosocial concepts. The course of theprogrammes showed the need for protocols with awell-defined target group and support offer, and aclear-cut working plan.

Keywords: refugees, psychosocial, mentalhealth, genocide, Rwanda

IntroductionUntil the 1990’s, it was widely believed thata stabilized situation was a precondition fora successful psychosocial care programmefor refugees. Today however, after the mul-titude of psychosocial projects in Kosovo in2000, the provision of psychosocial care

during the emergency phase of a refugeecrisis seems to be generally accepted. There is great variety in the historical, polit-ical, social and cultural contexts of refugeecrises, and refugees’ psychosocial needscannot be addressed adequately without tai-loring interventions to these contexts.Factors such as the populations’ prior cohe-sion or the recipient country’s attitudetowards an influx of refugees may play adetermining role in what is needed and fea-sible. It is impossible, however, to foreseethe contexts of future refugee crises. Muchof the essential information, such as thecomposition and actual location of a strick-en population, can only be gathered once acrisis takes place. Therefore, ready-madeprotocols are either lacking or running therisk of being inadequate. Besides, the help provided by different aidorganizations under the heading of‘psychosocial’ is diverse. It has become thesubject of considerable debate surroundingits (cultural) adequacy and effectiveness,without any recourse to data evaluationstudies (Bracken, Giller, & Summerfield,1997; Mooren, de Jong, Kleber, Kulenovic,& Ruvic, 2003; Strang & Ager, 2003;Summerfield, 1998, 1999).Clear definitions and protocols will increasethe pace of implementation, and establish

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Willem F. Scholte et al

A protocol for psychosocial intervention in refugee crisis;early experiences in Rwandanrefugee camps

Willem F. Scholte, Willem A.C.M. van de Put, Joop P. de Jong

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structured management and improvedaccountability of intervention programmes.In pursuit of guidelines with built-in proce-dures to adjust interventions to various con-texts and circumstances, the Dutch sectionof Doctors Without Borders (MédecinsSans Frontières, MSF) developed an inter-vention model directed specifically to psy-chosocial assistance in the acute phase of ahumanitarian crisis. The interventionmodel, called Emergency PsychosocialCare (EPSoCare), was designed in 1994 onthe basis of previous programmes and anumber of exploratory missions in disasterareas and/or refugee situations (Uganda1992, Sudanese refugees 1993, Burundirefugees 1993, India 1993). Its first applications took place in the after-math of the Rwandan genocide. In 1994 anunprecedented explosion of violenceoccurred in Rwanda and an estimated800.000 people died within a few months(UNHCR, 2000). A large outflow ofrefugees occurred and refugee camps wereconsequently established. As part of theemergency response, MSF carried out psy-chosocial intervention programmes in twolocations. In this paper we will address the conceptualframework underlying the EPSoCaremodel, the model’s first applications, theproblems encountered while applying themodel, and the lessons we learned.

EPSoCare’s conceptual frameworkThe model is aiming to provide support forpeople with psychosocial problems. Theterm psychosocial problems here refers toeither psychological problems arising froma disturbed social situation (e.g. depressionresulting from social isolation) or socialproblems stemming from mental disorder(e.g. violent conduct resulting from emo-

tional hyperarousal). Following the EP-SoCare intervention model, the supportprovided is primarily directed towards theindividual’s social re-integration. It is not somuch psychotherapeutic in nature, butrather focusing on the reinforcement ofsocial relations, networks and institutionswhich enable people to find support fromeach other: the community’s own supportcapacity. Two characteristics of the interventionmodel are essential. Firstly, the interventionshould be embedded in a comprehensiverelief programme. It presumes cooperationwith other aid programmes to ensure theprovision of basic needs such as food,water, shelter and sanitation, as well as pos-sibilities for referral to social assistance andpractical care facilities. Secondly, the inter-vention should aim to improve existingmutual support mechanisms in the targetgroup, since these may not only allow mem-bers of the community to come to termswith shock experiences (Solomon, 1986;Summerfield, 1992, 1998), but also facili-tate rehabilitation of the community as such(Volkan, 2001). Although the effects ofshocking experiences have a certain univer-sality, important culture-specific differencesexist in interpreting and coming to termswith trauma (Bracken & Petty, 1998; deJong, 1992; de Silva, 1993; Eisenbruch,1991; Helman, 1990; Marsella, Friedman,Gerrity, & Scurfield, 1996).Therefore, anthropological knowledge ofthe community concerned is essential.Social norms, beliefs, customs and copingstyles prevailing within the communitymust be identified. The supporting poten-tial of social circles such as may be formedby religious, professional, tribal or familiarrelatedness must be valued and mobilized.Because of their knowledge of, and partici-pation in the refugee community, members

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of the community itself are the designatedimplementers of the intervention. Different phases in a refugee crisis deter-mine different needs and consequently dif-ferent types of programme activities (seebox 1). In most refugee crises, the first daysto weeks of unpredicted refugee influx arecharacterized by chaos. Physical survival,basic needs and acute medical aid constitutepriorities. In this phase the programme’scoordinators, minimally two professionalswith clinical psychological and anthropo-logical expertise, are already on the spot.An anthropological assessment will helpidentify key informants among the popula-tion, which will in turn lead to the recruit-ment of a first small team of refugees.These will be instructed to find thoserefugees for whom, as a result of emotionaland physical exhaustion, the threat of totalcollapse is most acute. A very basic one daytraining will allow the team to refer thesepeople to relevant and available resourcesfor help in the camp. In this phase, the inter-vention is thus solely aimed at ensuring that materi-al and physical help are made available for those whoare not able to come and collect it themselves. Here,the target group consist of manifestly con-fused, bewilderd, apathetic or withdrawnpersons; those who have mental problemsbut yet are capable to take care of their mostbasic needs should be identified later.A next phase (the first weeks to months)may show growing coordination of emer-gency aid, while social structures among therefugee population have not yet stabilized.Most families are still occupied by gainingand maintaining control over an uncertainand unpredictable situation and over theirown functioning. An emotion focused ther-apeutic approach could have an undermin-ing effect at this time, especially in singlesession techniques or if therapy is unsys-tematic (Littrell, 1998; Wessely, Rose, &

Bisson, 2000). Apart from this, debriefingor any psychotherapeutic activity requiresthorough and prolongued training andsupervision. The intervention’s main focus in thisphase is to strengthen existing coping mechanisms, tocombat social isolation, and to further reassuranceand normalization by systematically providing infor-mation on common stress reactions which may beexperienced without an understanding of their ori-gin. The goal is to facilitate the reconstruction ofthese basic coping mechanisms and social structuresthat were devastated by the crisis.The team now consists of two to threeexpatriate specialists and five to fifteenrefugees, who have been identified as eligi-ble through key informants among therefugees and local CV-files of the UnitedNations High Commissioner for Refugees(UNHCR, the United Nations’ refugeeorganisation responsible for the coordina-tion of the aid to refugees). In an interactiveand ongoing process the team gathers cul-ture-specific and situation-based relevantinformation. Within the team, it discussesthe relevance and applicability of basic psy-chology and psychopathological reactions,and sets out the details of the programme.It designs and implements a short trainingcourse for those who are most in touch withthe community: community leaders (e.g.teachers, religious leaders) and communityworkers (social workers employed byhumanitarian agencies).The course focuses on the recognition ofpsychosocial problems, and the applicationof an intervention directed at re-integrationof the individual into his/her social context.Main elements of this intervention are toraise awareness of, and provide informationon psychological issues; to give behavioraladvice to individuals as well as the peoplearound them (e.g. the advice not to with-draw but to share time together, to seek orprovide emotional support, distraction or

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184


Activities

Expatriates

Identify first refugee staff, provide one-day training and supervi-

sion

Refugee Staff

Identify the most emotionally/physically debilitated individuals,

connect these to food/water distribution, material and health care

Expatriates

• Anthropological assessment.

Recruit refugee staff and outreach workers1

• Train and supervise refugee staff

• Connect with other agencies

• Prepare therapeutic interventions (with refugee staff)

• General coordination and monitoring

Refugee staff

• Train and supervise outreachworkers

• Train community leaders/workers and medical personnel

• Install referral system from/to medical facilities and community

services

• Prepare and carry out psycho-education campaign

• Prepare therapeutic interventions

Outreach workers (included after the experience in Katale camp)

• Identify problem cases and provide/mobilize support aiming at

social reintegration

• Provide consultation to community leaders/workers and med-

ical personnel

Expatriates

• Continue coordination, training, supervision and monitoring

• Prepare close down or hand-over of programme

Refugee staff

• Continue training and supervision

• Apply therapeutic interventions for groups

Outreach workers

Continue provision of support and consultation

Objectives

Connect the most

debilitated individu-

als to the emer-

gency aid

Installation of com-

munity based psy-

chosocial support

system, aiming at

social reintegration

Consolidation of

support system

Application of ther-

apeutic group inter-

ventions

Preparation for

closing or handing

over programme

Characteristics

Influx of

refugees

in area/camp

Mental shock

Arrival of first

emergency aid

Lack of social

structures,

chaotic living

circumstances

Struggle for life

Growing coordi-

nation of

emergency aid

Recognizable

living pattern

and social struc-

tures

Basic security

Available basic

material

resources

First

Phase

Second

Phase

Third

Phase

Time plan

Within days

Within

1-2

months

Within

5-6

months

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practical help, or to fulfil certain activities orpursuits); to guide people to related com-munity members who could provide sup-port (relatives, neighbours, fellow-believers,etc.); to refer people to health or communi-ty services where necessary (e.g. in case ofphysical disease or obvious material needs).The help offered is thus very much in linewith existing social patterns and prevailingcoping mechanisms. At the same time the team translates infor-mation, gathered from the start of the pro-gramme, into a psycho-education cam-paign. Psycho-educational materials willcontain culure-relevant information, e.g.they will avoid using concepts and wordsthat may lead to misunderstanding, andmention those expressions of distress andcoping mechanisms that are known to thepopulation. The campaign is directed at thecommunity at large, to raise awareness ofthe mental health issue, to provide informa-tion on common stress reactions and how todiscriminate these (continuity, duration)from pathology, and to indicate ways to pro-vide and receive emotional support. Allavailable and adequate communicationtools are utilized, such as brochures/newspa-pers, group discussions, theatre, and radio. A later, third phase can be spoken of whenthe community shows some stability ofstructure and order. Problems and/or symp-toms, however, may persist in spite of thesocial surrounding’s support capacity.Interventions now aim to provide emotional supportthrough communal therapeutic activities. The indi-vidual or family concerned is offered admit-tance to culturally adequate and applicabletherapeutic group activities, prepared by theteam in the second phase during an interac-tive process as described above. The thera-peutic groups are composed of memberswho show a natural cohesion, such aswomen, children, elderly, neighbors, or reli-

gious groups. Depending on the nature ofthe activities, groups can contain up tosome thirty people. Activities can vary fromcraft or artistic skills to rituals or verbalexchange, depending on what is commonlypracticed by the population as an activityproviding emotional outlet or healing.A final step in the programme is to decidewhether, after about a half year’s presence,it is to be closed down or whether the activ-ities need to be continued in another set-up.Criteria to base this decision on should beformulated per context, at the start of theintervention.

The model’s first applicationsThe first programme following the modelwas run in Tanzania, around the village ofNgara, in a group of four refugee campswith a combined population of 360.000.The second programme was run in the for-mer Zaire, in the Katale camp providingshelter for 230.000 refugees1. This campwas formed after hundreds of thousands ofRwandans flooded into the town of Gomawithin days, many of whom died fromcholera shortly after arrival. The psychosocial programmes ran for 18months in the Ngara camps (starting June1994) and for 12 months in Katale (startingOctober 1994), where it was integrated intothe MSF emergency programme only afterthis had already been running for fivemonths. In both locations teams composed ofexpatriates (an anthropologist, a psychologistand a psychiatric nurse) and refugees imple-mented the programmes in what turned outto be quite different kinds of settings.The Ngara camps. An anthropologist waspresent from the moment the first campwas established. Principal tasks were theintegration of the psychosocial element intothe MSF programme, monitoring the con-struction of social structures within the

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camp community and, via personal con-tacts with the refugees themselves, andestablishing teams in each of the four campscovered by the programme. The teamstogether contained an average of 25 mem-bers through the course of the programme.Clear explanation of the objectives of theprogramme resulted in good cooperationwith other aid agencies not primarily pro-viding psychosocial care, whose communi-ty workers were eventually trained by theprogramme’s teams. Within one year, 2250community workers were trained in theidentification of possible clients and inmobilizing support. Ultimately, and despiteinitial resistance, it was possible to train allmedical facility personnel in the identifica-tion of psychosocial problems. Psycho-education was carried out for thegreater part through mass distribution ofbrochures. The team estimated that half ofthe camp population was literate, whichthey believed would guarantee at least oneindividual in each tent or hut being able toread the brochure. A total of 75.000brochures were distributed, providing infor-mation about stress, normal and pathologi-cal stress-reactions, possible ways to helpeach other, and how to access the additionalhelp available in the EPSoCare programme. The expatriate teams decided not to imposeany clinical (perhaps culturally inadequate)standards on the refugee teams members.The population itself made the ultimateselection; whoever registered for the programme, or was referred by his/her rela-tives, neighbours or community workers,was in principle offered help through to theprogramme. The majority of peopleappeared to present with symptoms which,in DSM-IV terms, would fall under thePTSD cluster, or depression, or dissociativedisorder (American Psychiatric Association,1994). There also were frequent calls for

individual or medical care, e.g in case ofpsychotic states.In the teams’ effort to provide support,many individuals were offered long-termand frequent contact, although individualassistance was not the EPSoCare model’spreferred choice. Ultimately, the teamsthemselves gave support to 392 individuals,including 60 children. The total number ofpeople reached by the programme wasmuch higher, but the large number of com-munity workers trained by the teams madeit impossible to monitor (and supervise)their supportive activities. Katale camp. The camp was badly co-ordinat-ed. Because no agencies employing commu-nity workers were present for a long time,the EPSoCare staff employed and trained agroup of 18 ‘outreach workers’, who wereactive throughout the camp (see figure). Theteam also arranged training for roughly 300health workers and, once community work-ers were present, 220 were also trained.In designing the psycho-education cam-paign, the team, in contrast to Ngara, con-cluded that literacy would be a problem.Psycho-education took the form of face-to-face contacts, group discussions and role-play, which would also serve the interests ofgaining immediate response; there was thusless chance of misunderstandings arising,e.g. concerning terms used. It was also pos-sible to combine educational information-provision with care-giving : team memberswere immeditely confronted with individu-als’ actual problems, and consequentlystarted giving advice or mobilizing supportfrom others. As in the Ngara programme, and conse-quent to the contextual sensitivity inherentin the working model, no clinical criteria toenter the programme were set on before-hand. Clients presented with the same cate-gories of symptoms as in Ngara.

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The programme’s own outreach workersultimately helped 1343 people. They sawclients on average twice a week over a peri-od of five months. The outreach workers,each of whom had a clearly defined work-ing area within the camp, were monitoredand supervised by the team. Contacts withclients were primarily supportive andinformative by nature, and were regardedas essential in replacing community supportthat was absent in this politicized setting. Ata later stage, two experimental ‘third phase’activities were carried out: Cooperationwas established with an organized group ofpracticing traditional healers present in thecamp, and a therapeutic activity centre wasinstalled for women and children with psy-chological problems that had resulted inextreme social isolation. The objective of thiscentre was to reduce stress complaints and toincrease the activity level and number ofsocial contacts during a four weeks pro-gramme. Women were involved in incomegenerating activities like weaving basketsand repairing clothes; activities for childrenincluded drawing, drama and singing.

Problems in applying themodelThe teams encountered success and hard-ship in implementing the model.Community workers were trained, out-reach programmes were started, medicalstaff was trained, psycho-education wasdelivered, and last but not least: clients wereidentified and helped. The coverage inKatale was small, and the total coverage ofthe Ngara programme is unknown. Theproblems encountered in the implementa-tion came in different kinds. We will listthem here in chronological appearance, anddiscuss their backgrounds below. A continuous problem was the security sit-uation, which impacted implementation of

the programmes from the level of access tothe target population, selection of staff anddevelopment of communication, to theidentification of local support mechanisms.In combination with the time taken bydevelopment of psycho-education material,this delayed operationalisation of themodel. Referral options proved to be limit-ed. The overall inexperience in carrying outa psychosocial support programme added todelays. Collection of data was not possibleas foreseen. And in the course of the inter-vention it became clear that it was extreme-ly difficult for the teams to decide who was,and who was not to be identified as ‘some-one with a psychosocial problem’. The pres-sure on the teams to accept all as individualclients impeded timely development andimplemention of group-interventions.

Lessons learnedThe EPSoCare working model is designedfor rapid psychosocial interventions. In thechaotic situations in both Ngara and Katalecamps, working with the model provided atleast minimal structure and logic in prepar-ing psychosocial interventions. The essen-tials of the intervention could be carriedout. The structured approach allowed mon-itoring of the implementation process fromthe start, and helped the teams to provideinterventions within a relatively short timespan – although there were severe con-straints that originated from diverse factors:The socio-cultural background of the Rwandanpeople. The teams encountered great diffi-culty in identifying existing local supportmechanisms. In Katale camp, practicallyevery family had lost one or more relatives,either during the war or because of thecholera epidemic. Mourning made the struggle for survivaleven more difficult, and the loss of a mutu-al bond resulted in little willingness to give

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mutual support. Security issues were alsoimportant here. Katale camp was dominat-ed by well organized Hutu militias, whichhampered the establishment of alternativesocial structures, as was noticed while con-sidering potential use of the scouting move-ment that had been very strong in Rwanda.Any organized tasks carried out by thescouts, however, was seen as a threat by themilitias, and scouts actually have been killedfor it.The development of psycho-educationmaterial was more time-consuming thanexpected. Coming to agreement, within theteams, on the exact wording of messagesthat would be appropriate to the total pop-ulation was a painstaking process in itself.Correct, meaningful translation of concepts(e.g. ‘being nervous’) that were new tomany was an underestimated process in themodel-design, and literate Rwandans wouldnot use the same wording for the same phe-nomena as illiterate people. Once a cultur-ally appropriate text was agreed upon, massdistribution of brochures turned out to bean effective way to provide psycho-educa-tion in Ngara, where the majority of thepopulation was literate. Psycho-educationvia face-to-face contacts, given by the teamitself as done in Katale, is immediate, offersthe possibility of further discussion, andmerges information-giving with support-provision. Coverage, however, easily getsreduced and unsystematic. In group discus-sions and role-plays there is a risk of stigma-tization or reprisal; this should be mini-mized by skilled guidance, protecting indi-viduals by only demonstrating and allowingconstructive comments.While security issues are relevant in manyrefugee settings, there were specific ele-ments for the Rwandan crisis. The ongoingintimidation and political activity was acontinuation of a process that eroded mutu-

al trust in Rwanda for decades. The com-plex pattern of disintegration of the socialfabric of Rwandan society, leading to moreinsecurity and consequently more fragmen-tation is an important factor in the originsof the genocidal killings as much as a factorin blocking healing processes. The actual situation in the camps. Within thecamps, security was a problem on all levels.Victims and aggressors, political activistsand neutral civilians lived side by side.Conflict continued in the camps, murderstook place on a regular basis, and peoplewere afraid to speak out. Selection of localteam members was complicated by actuallyhaving to include a check on involvementin the earlier killings (which obviouslycould only be done through personal inter-viewing and checking formal records).‘Innocence’ thus became a selection criteri-on that sometimes preceded competence.This affected trust between the local teammembers, and some feared they would beseen as political activists working under thedirection of western powers. The fear heldby many refugees that there would bereprisals if they spoke out about the vio-lence they had experienced further compli-cated the process of entering into dialoguewith the community.While the interventions’ main objective,social reintegration, presumes some cohe-sion and solidarity within the community,political insecurity in the camps prohibitedthe re-creation of communal networks. Thistempted helpers to develop a strong senseof attachment with clients, which lay at thebasis of the emphasis on long-term individ-ual contacts, and in turn may have causedfurther demotivation of potential socialresources: others may have started to counton ‘outside help’ instead of taking initiativethemselves.Another important assumption in the inter-

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vention model was the availability andaccessibility of social and medical services.Community workers, however, were non-existent for a long time in one of the pro-gramme locations (Katale). Final responsi-bility for the provision of services forrefugees is with the UNHCR, and theresponsibility for social services was nottaken. In consequence, there was no oppor-tunity to refer people to such facilities. There was resistance of medical staff inbeing trained in psychosocial concepts bythe Epsocare team. This was in part due tosocial status: medical staff did not want tobe trained by refugee team members whowere not medical doctors. Another aspectwas the fear of medical staff, feeling heavilyoverburdened, that psychosocial and men-tal health awareness would rather add totheir workload than lessen it. It took muchlonger than expected to address this viciouscycle. Finally, it was recognized on clinicalgrounds, and later quantified by means ofsystematic research (de Girolamo, 1990;Scholte, de Jong, de Groot, & de Haan,1995) that one third of those attending thefield-clinics were seeking help for com-plaints that indicated somatized psychoso-cial problems. This helped to convince thestaff that was a need for awareness. Theinexperience of the general MSF team,where doubt existed initially about whetheran early psychosocial intervention was bothhelpful and feasible, was one factor in thedelay of relevant training.This absence of experience slowed downboth the start and the general course of theprogramme. There was at the time no‘pool’ of qualified candidates to implementthe project, and a lack of existing materialon which to build training curricula. In view of the growing demand for an evi-dence base for humanitarian interventions(Banatvala & Zwi, 2000), the pilot

EPSoCare projects sought to monitor theefforts made. In humanitarian crises, orga-nizational reasons as well as ethical consid-erations constrain methodology forresearch. The first difficulty was in estab-lishing a functional information system tomonitor clients and activities of the out-reach workers. The refugee team memberswere not able to systematically collect data.In spite of continuous supervision, docu-menting contacts with clients proved to betoo problematic for local staff. They hadtechnical difficulties in systematicallyrecording and coding data (e.g.: demo-graphics, symptomatology, action taken,outcome), but, more importantly, alsofound it difficult to apply these systematicsin their emotional role of care-provider.Security prevented others from actually get-ting the job done, as data-recording had athreatening effect on the refugees in a situa-tion where death-lists had been used.Monitoring the achievements of the largenumber of trained community- and healthworkers turned out to be a practical impos-sibility, which impeded quality control andevaluation of the programme. At the time, we also considered it as ethi-cally unacceptable to identify, assess andfollow-up individuals in psychological needto act as a control group for the sake of arandomized controlled trial. Next to that,tension in the camps did not allow for tak-ing unbiased and safe interviews in siteswhere the teams had no contacts yet and nointerventions were scheduled. There wereinsufficient resources and time to explorealternatives, such as comparing the effect ofdifferent interventions. At both locations,the involvement of MSF in the psychosocialinterventions ended abruptly. As a result ofthe politicizing of the camps and the misuseof relief supplies, MSF withdrew all its pro-grammes as soon as it became apparent that

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there was no further reason to speak of amedical emergency. The psychosocial pro-grammes had to be handed over rapidly toanother international agency that decidedto stay, before third phase interventionscould be completely implemented.The conceptual model itself. A major shortcom-ing of the model was that it offered no pre-cise definition of the nature of solutions thatwould be pursued in case of psychosocialproblems. It was assumed that trained out-reach workers would try to re-establish con-tact between clients and resources for socialsupport in the camp, and this turned outnot sufficiently to be the case. The modeldid not provide guidance in dealing withthe exceptional complexity and fragmenta-tion of the social fabric in the camps. Thecommunity and group interventions wehad expected to develop in the course of theproject materialized very slowly, leaving theemphasis of the work on ‘general’ psycho-education and individual support.Groupwise practical engagements can betherapeutically effective, even if, for cultur-al or security reasons, participants may notdisclose themselves easily. We observedthat the activity centre in Katale enabledgradual and careful mutual exploration,thereby enhancing mutual support.Therapeutic group approaches probablycould have been set up earlier. Focusing onsocial reintegration and using therapeuticapproaches, though separately mentionedin different phases of the EPSoCare work-ing model, cannot be strictly separated inpractice.Also, a clear definition of what would con-stitute a ‘client’ for the programmes was notavailable. The current debate on the ade-quacy of psychosocial interventions inhumanitarian crises (Bracken et al, 1997;Summerfield, 1998, 1999) comes down tothe question if one can clearly define which

individuals need help from outside, whyand how (are we imposing western/medicalstandards and practices?), and whetherscreening and outcome instruments areavailable with proven validity in the specif-ic linguistic group and culture. The level ofmental health problems (defined as justify-ing a support offer) among the refugees wasestimated as extremely high (de Jong,Scholte, Koeter, & Hart, 2000). The mostimportant criterion according to the modelwas the level of self-sufficiency of familiesor individuals. But while in any situation itwould have been difficult to stick to a defi-nition of self-sufficiency, the conditions inthe camps made it hard to refuse anyrequests for help. The emphasis was on thecommunity’s demand, rather than on staff’sassessment: active case-finding was donethrough the population itself. Individualswith psychosocial problems were indicated tothe outreach/community workers by theirown social surroundings (which, admittedly,carries the risk of bias of all kinds).Consequently the teams felt no need for ascreening instrument. Besides that, no screen-ing or outcome instruments with provenvalidity in this specific linguistic group andculture were available, and time was too shortfor their development on the spot. The EPSoCare model did not provide a suf-ficient answer to the frequent calls for indi-vidual, medical care. For psychiatric cases, apsychosocial approach wasn’t always themost adequate response, while at the sametime ‘de-medicalizing’ psychosocial prob-lems was one of the model’s objectives.

Conclusion There is a need for ready-made workingplans for rapid post-war psychosocial inter-ventions, which are appropriate to differentcircumstances and cultures. In protocols, itshould be clearly defined which people will

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be considered for support by the pro-gramme, and how these individuals will befound in the community or selected fromthose seeking help. Interventions should contain an operationalresearch component to improve our knowl-edge of psychological morbidity in emer-gencies, and to be able to demonstrate thevalidity and effectiveness of methods. Themethodological problems met in the pilotinterventions described here were not inher-ent to this particular refugee crisis’ character-istics. In any humanitarian emergency inter-vention, the formation of control groups,case definition, cultural validation of instru-ments and systematic data collecting will beextremely complicated. In the EPSoCare model, the idea is to limitinterventions to social reintegration in thefirst phases, while later on therapeuticapproaches can be provided for those whoneed more individual help. The attempt to‘de-individualize’ psychosocial problemswould have benefitted from earlier involve-ment of medical staff – who could havereferred individuals to groups, while out-reach workers could have referred some oftheir case load to health staff. Also, obviouspsychiatric symptoms need to be addressedprimarily at a medical level. As for the security situation, the vicious cycleof violence, lack of trust, eroding mutualsupport leading to more violence was clearlya serious obstacle in the programme’s imple-mentation. In itself this is by no means anargument to ‘wait for security’ – but ratheran argument to focus interventions in gener-al on precisely the aspect of ongoing insecu-rity. A condition for future psychosocialinterventions is that the international com-munity present guarantees a minimal level ofsecurity.

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1 We thank the Rwandan EPSoCare teamfor their great courage and effort. TheNgara programme was funded byUNICEF and the Dutch Ministry ofForeign Affairs, the Katale programme wasfunded from private donations to MédecinsSans Frontières Holland.

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Willem (Pim) Scholte, psychiatrist, has been anadvisor and is a trainer for MSF-Holland. Heworks at the Academic Medical Center inAmsterdam.Willem van de Put, medical anthropologist, hasbeen a health advisor for MSF-Holland.Currently he is the director ofHealthNet International in Amsterdam.Joop P. de Jong worked as a physician for theEPSoCare program in Tanzania. Currently heis a psychiatrist, working at Parnassia psy-chomedical center in The Hague. Address for correspondence: Pim Scholte, MD;University of Amsterdam; Academic MedicalCenter; Dept. of Psychiatry; Tafelbergweg 25;1105 BC Amsterdam; The [email protected]

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