The United Nations Children’s Fund (UNICEF) estimates around 33 million people, including approximately 16 million children, have been affected by this year’s heavy monsoon rains in Pakistan, which have brought devastating rains, floods and landslides. The biblical floods have washed away entire villages, leaving millions in need of immediate, life-saving support, as well as an increased risk of waterborne diseases and malnutrition.

As the floodwaters recede, they are revealing the sheer scale of the widespread damage. Hundreds of thousands of homes have been damaged or destroyed, including public health facilities, water systems and schools. Families are living out in the open with no drinking water, no food and no livelihood, exposed to a wide range of new flood-related risks and hazards, including from damaged buildings and drowning in still-standing floodwaters.

The human cost of the tragedy is ten-fold that of the loss of life, property and infrastructure.

There have been several horrific stories of flood affectees — watching their loved ones being swept away by the unforgiving waters, parents being compelled to make tough decisions such as whether to save their drowning child or the cow that could feed their six remaining children, or leaving behind their dying parents in order to save their children and so on. Making such heart-wrenching, tough decisions would be trauma-inducing for anyone, let alone someone who is also experiencing a complete disruption of their livelihood.

The psychological effects of the devastation caused by the floods are more drastic among children, women and the elderly population. It is imperative they receive psychosocial support

A medical camp arranged earlier this month at the TH Hospital Taunsa Sharif by the Psychiatry and Behavioural Sciences Department of Nishtar Medical University, in collaboration with the Pakistan Psychiatric Society, found that people visiting the camp were suffering from post-traumatic stress disorder, depression and anxiety. The psychological effects of the flood are more drastic among children, women and the elderly population that is dependent on others.

Natural calamities such as floods put significant psychological and social stress on individuals, families and communities. People not only experience distress during their migration, but their squalid living conditions at relief camps also impose significant mental distress.

Those displaced experience grave loss, pain, disruption and violence, which negatively influences their mental health, psychosocial wellbeing and increases their vulnerability to psychological problems. Young children, especially, may have different ways of experiencing and expressing distress and adjusting to their new reality.

Those who have lost, or been separated from, family members, or who are survivors or have witnessed violence are more vulnerable to developing chronic psychological issues. Most people are able to cope with difficult experiences and may become more resilient if a supportive family and community environment is available. This is usually referred to as psychosocial support. In a collectivist society like Pakistan’s, one of the biggest sources of distress in such a calamity is the dismantling of this psychosocial support.

When mass displacement occurs, the traditional familial and community structures — a joint family set-up, extended family systems and close-knit neighbourhoods — that often regulate community well-being, crumble. This can result in or exacerbate psychological issues in individuals. There is an increased risk for people in such situations to employ maladaptive coping mechanisms to deal with their situation, such as substance abuse or violence.

Mental Health and Psychosocial Support

According to UNHCR, the UN agency for refugees, the composite term ‘Mental Health and Psychosocial Support’ (MHPSS) refers to any type of local or outside support that aims to protect or promote psychosocial wellbeing or prevent or treat mental disorders. The term is widely used among humanitarian agencies and serves as a unifying concept that can be used by professionals in various sectors.

MHPSS interventions can be implemented in programmes for health and nutrition, protection — community-based protection, child protection and in dealing with sexual or gender-based violence (SGBV) — or education. ‘MHPSS problems’ is an umbrella term that covers a wide range of issues, including social problems, emotional distress, common mental disorders (such as depression and post-traumatic stress disorder), severe mental disorders (such as psychosis), alcohol and substance abuse, and intellectual or developmental disabilities.

It is, hence, important to first identify what psychosocial skills are and outline what psychological first-aid entails. Training should then be given to emergency responders and primary health workers for the provision of psychological first-aid and basic psychosocial support skills, as part of an emergency response programme.

It is imperative that, after a natural disaster, psychosocial supports are integrated within other pre-existing community services and networks. For example, Pakistan has roughly 100,000 community health workers hired under the Lady Health Workers Programme (LHWP), according to the International Growth Center (IGC). They can be utilised and trained in providing psychological first-aid at relief and medical camps.

Nargis Asad, Chair of the psychiatry department at Aga Khan University emphasises the need for early interventions. She explains that, in disasters of such nature, immediate needs will be that of physical survival (food, shelter, clothing, medical aid). When these are met, needs assessment has to be done for psychosocial support to devise contextually relevant support strategies. There will definitely be a need for long-term planning for rehabilitation of the survivors.

“Rehabilitation will have to be in all aspects of life and basic needs, such as shelter, education, employment and health, will have to be fulfilled,” she says. “Rehabilitation focused on resilience-building, helping people to be self-sustainable, will lead to a sense of security and better self-esteem and consequently positive mental health.”

She adds that the focus should first be on physical safety and then screening and connecting with support resources for acute and chronic mental health needs.

To mark World Mental Health day on October 10, Pakistan launched the Mental Health and Psychosocial Support (MHPSS) model; it is multilayered, digitised, rights-based, scalable and sustainable on the guidelines of the World Health Organization (WHO). The project, which was first initiated globally in 2016, will be first implemented in the Islamabad Capital Territory in collaboration with WHO, the health ministry and the planning commission.

Its goal is to provide mental health and psychosocial support through intersectoral collaboration. There is an urgent need to utilise the MHPSS unit to facilitate the psychosocial rehabilitation of flood victims. If this is not done, there will be a cost to pay in terms of volatile law and order situations, civil unrest and social upheaval, resulting from the socio-economic repercussions of the flood.

The Pakistan Mental Health Coalition (PMHC), which advocates for the development of comprehensive national and provincial mental health legislation and strategic plans using a multisectoral approach, has drafted a Flood Relief Mental Health Response.

Their three-tiered model is divided into primary, secondary and tertiary levels. At the primary level, the interventions with the highest priority include psychological first-aid training for frontline relief workers and allied workers (teachers, community health workers, social workers, lady health workers, community youth volunteers). Coping-skills groups, psycho-education and associated risk mitigation (such as for sexual violence) are other proposed interventions.

At the secondary level, the required interventions include on-ground lay counselling, and psychological and psychiatric support in medical camps. Additionally, training of general practitioners (GPs) should be conducted to handle mild to moderate mental health problems in medical camps. Tele-mental health services can be effectively utilised at this stage because of their scalability and convenience. Numerous organisations are now providing these services free of cost or at nominal rates nationwide, such as Umang, Taskeen and Sehat Kahani. Provision of telephonic counselling, therapy and medication management can be done this way.

Taha Sabri, COO and co-founder of Taskeen, one such tele-mental health organisation, says, “Mental health interventions can only start after the initial needs have been met. Taskeen is waiting for the initial phase of the response to be over, and then we will launch telephone-based mental health support for the affectees.”

At the tertiary level, the objectives include urgent care services for beneficiaries experiencing a mental health crisis, and long-term psychiatric rehabilitation services for beneficiaries with chronic or severe mental illnesses.

An important factor towards rehabilitation is prioritising the normalisation of educational facilities, even in emergency stages of operations, since this provides significant opportunities for support to children and their caregivers. Government bodies should ensure that mental healthcare should be functionally linked to and integrated into the general health system, rather than establishing parallel mental health services.

The writer is a clinical associate psychologist and freelance journalist.

She can be reached at rabeea.saleem21@gmail.com

Published in Dawn, EOS, November 13th, 2022