The Crisis Inside

Just over a year ago, a large number of Rohingya refugees from Myanmar crossed the border into Bangladesh and crowded into and around existing refugee camps. While struggling to secure food and shelter for their families among hundreds of thousands others, they were grieving for lost family members and having to leave their homes behind.

It was more difficult to diagnose their mental health then. "They [refugees] were going through different stages of grief and stress at the same time—the stories they related were of traumatic experiences such as losing family members, seeing their homes and land destroyed, and having to walk so far to get to Bangladesh," says Anita Saha, a clinical psychologist who has been working in the camps in Ukhia and Teknaf for the past two years.

"We've seen many cases of post-traumatic stress disorder (PTSD) and other stress-related disorders," says Saha. Refugees also experience depression, anxiety, flashbacks, panic attacks, and insomnia. The causes result from past trauma as well as more immediate issues in their new surroundings, such as women suffering from increased domestic violence and abandonment in the camps.

Studies conducted among the Rohingya refugees confirmed this. Causes of PTSD ranged from traumatic events such as losing their land and homes, suffering beatings, and being forced into hiding, among others. These were, of course, triggered by their immediate situation in the camps where they faced hunger, were unable to move freely, and still felt unsafe and insecure.

Children, too, had been witness, or even subject, to horrific violence in Myanmar. Photo: UNHCR/Roger Arnold

"Within refugee situations, we commonly see shifting patterns of mental health issues. In the very beginning, mental health issues are strongly related to acute stress and acute grief, [but] refugees are also very much focused on surviving," says Peter Ventevogel, a UNHCR psychiatrist and expert in mental health in refugee settings.

"In intermediate stages, like now in Cox's Bazar, one would expect that many refugees will be able to go on with their lives, but a subgroup of people will show persistent symptoms of depression, PTSD, and anxiety. They need more focused support such as psychotherapeutic interventions," he adds.

Saha supervises 11 mental health service centres run by the women and children's affairs ministry in the camps. The one-stop crisis centre, where we met, has 10 clinical psychologists on staff and is situated near the entrance of Kutupalong megacamp.

Saha has treated many cases of severely traumatised patients who require ongoing treatment. "They are still in those memories and cannot adjust to the present. They're having flashbacks," she says.

For such cases of PTSD, Saha said their main approach was cognitive behavioural therapy (CBT) and particularly, trauma-focused CBT. The latter utilised techniques to return them to their previous state (with normal thinking and functioning) and involved conducting up to 16 one-on-one therapy sessions with patients.

Such therapy requires time to absorb and practice, explains Saha. Other coping strategies were regularly taught to help refugees manage their stress. Severe cases, of course, required psychiatric treatment. "They were not in any state to adopt techniques and needed medication urgently in order to become stable," says Saha.

Children, too, had been witness, or even subject, to horrific violence in Myanmar and for them, therapeutic play sessions were offered at child-friendly spaces and counseling centres.

The mental health of the refugees also has consequences for future generations. A 2017 report on the Rohingya refugees in Bangladesh noted that poor mental health due to trauma and PTSD coupled with a lack of opportunities and hope for their children was likely to result in an "unconscious lack of childcare".

There is no term for mental illness in the Rohingya language, and refugees generally tend to speak about whether they are in a peaceful state or not. Photo: UNHCR/Roger Arnold

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PTSD and depression are not unique to newer refugees [who arrived post-August 2017], but is also present among older refugees who have been living in the camps for decades. A survey in the registered refugee camps in Kutupalong and Nayapara in 2017 found that this was due both to trauma from their experiences in Myanmar and their continued displacement (with the accompanying struggles). These were compounded by a lack of specialised mental health and general psychosocial services in the camps.

Over half the Rohingya refugees surveyed said their mental health and overall well-being would improve if they had a lasting solution to their current state—chiefly, stable living conditions, safety and security, and more food aid.

"Daily stressors" in the refugees' immediate environment, as compared to past trauma in Myanmar, was found to have a much stronger and more direct effect on depression. Depression was found to occur more frequently to women and older refugees.

"In protracted settings such as was the case in the old camps with registered refugees one sees that the role of daily stressors becomes bigger and bigger, as people get demoralised and lose hope," says Ventevogel, one of the authors of the study.

Psychologists are not the only ones to receive patients with mental health issues. In the camps, refugees would present with physical issues which mental health workers say are somatic symptoms (physical distress which can occur if trauma is kept inside) at the hospitals and counselling centres. In the 2017 study in the registered camps, over half the refugees had somatic complaints—such as medically unexplained headaches and back pain.

A family doctor volunteering at a field hospital for women run by the Hope Foundation in the camps says, "We see patients here every day, most of whom have mental health issues such as PTSD. They are still mentally scarred from the violence they suffered back in Myanmar." Most patients come because they get no sleep at night, she adds.

Refugees experience depression, anxiety, flashbacks, panic attacks, and insomnia. Photo: UNHCR/Roger Arnold

There is no term for mental illness in the Rohingya language, and refugees generally tend to speak about whether they are in a peaceful state or not. Jamil, a 26-year-old refugee in Kutupalong, told Médecins Sans Frontières (MSF) that he had lost weight and energy since coming to the camps, as he was "not peaceful". Another refugee, 40-year-old Mabia, said she constantly recalls what happened back in Myanmar. "I will never forget what happened in Myanmar. Sometimes it comes back to me. I feel unhappy when I think about it. I can't sleep and I have body pains. I get dizzy when I think about it."

Some turn to traditional healers and religious leaders. Others, however, are taken care of by family members, forgoing formal help altogether.

Those who have no one, have nowhere to turn to. At Balukhali camp, we witnessed one woman who was mumbling incoherently outside an army tent. A female Rohingya volunteer from her block, assigned to watch her, followed her there and was trying to take her back home. The woman dropped onto the ground, refusing to go. "She has no family members to look after her. We don't know why she comes here every day," says the volunteer.

When asked why patients like her were not receiving the care they need, Saha says they are forced to rely on patients' families to be the primary caregiver as they are unable to do this themselves for such a large population. "For those requiring psychiatric care, a caregiver is urgent to ensure the patient is taking their medication on time. It is a long-term process," says Saha.