Addressing Mental Health Needs of Migrants

ADDRESSING MENTAL HEALTH NEEDS OF MIGRANTS
Frame and Guidance on

Mental Health & Psychosocial Support (MHPSS) In Migration Contexts
Carmen Martnez Viciana, Mental Health Advisor, Medical Department, MSF-OCBA 2012
Table of Contents:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
Introduction
Key concepts and definitions related to Migration
Background of Migration
MHPSS Consequences of Migration
General Approach in MHPSS with Migrant Population
Interventions with migrants in Transit
Interventions with migrants in Detention Centres
Interventions with migrants Victims of Trafficking
Interventions with migrants in Destination
Considerations for the work with migrants children
Summary of some Operational Issues
Human Resources Issues
Conclusions
Additional Tools
References
1. Introduction
This document intends in the first place to be part of a dynamic process regarding the development of Mental Health
and Psychosocial (MHPS) operational issues related to migration in MSF. It is not a document about migrations in a
broader spectrum; thus only very basic and key concepts and ideas about migration in general will be addressed, in
order to facilitate the understanding of the subject. (See References in the end of the document).
Since the 90s MSF works with migrants in a situation of humanitarian crisis, lacking access to health care and facing
threats to their human dignity. MSF has gained an important experience in migration. OCBA counts with a history of
projects in Spain, Morocco, Greece, Yemen, Zimbabwe, and recently Mexico and Turkey. Other significant projects from
other sections were located in Italy, Malta, France, Switzerland and Belgium. Activities include response to emergencies
and life-saving, sexual and reproductive health, mother and child health, infectious diseases (preventive and curative;
TB, HIV, etc.), chronic diseases, nutrition, consequences of violence, mental health and psychosocial care,
accompaniment and referral to national health facilities, outreach to beneficiaries using cultural mediators, networking
and collaboration with authorities and other actors, and advocacy.
MHPS aspects in migration, including promotion, prevention and care are probably not enough addressed, and even
often neglected. Without the idea of psychologising, it is relevant to offer an integrated coverage regarding aspects
of adjustment, integration and daily functioning.
We should wonder ourselves whether there are specific psychological needs for migrants and asylum seekers; even
when we can find similarities with other groups such as victims of violence. And more than that, if the interventions
have to be adjusted to the specific contexts, cultural groups, rhythms and moments of the migration process. Based on
the inner nature of migration, a trans-cultural approach is compulsory; as well as the recognition of the psychological
and social reactions and changes of the persons living a situation of migration as natural and normal, responding to
demands and experiences.
Considering migration like a holistic and dynamic process, it is required to incorporate resources in projects in order to
provide integral and inter-disciplinary support (including or connecting with medical, mental health, social and legal
services).
Addressing MHPS Needs of Migrants. MSF-OCBA 2012
The evaluation finalised in October 2010, regarding MSF OCBA Migration projects (Greece, Morocco, and Yemen)
stated in its lessons learned that Research to develop guidelines on mental health in migrant interventions would be
very useful. Some issues (proposed) that deserve attention:
How to do mental health with population we see very shortly
Cultural issues (experience has demonstrated that when conditions are provided safe place, confidentiality,
freedom to talk patients seem to respond, but this would require further research)
Treatment of serious cases medicines, etc.
Referral possibilities
Mental health in detention settings
How to adapt to lack of local psychologists
Translation issues.
The present document aims to give at least some responses to these issues. Although of course there is a long way to
go through, learn, capitalize best practices, arise and face on-going dilemmas and improve our interventions. It should
not be taken as a blueprint, but more to raise issues and offer suggestions.
The same as with other target population, it is important to treat persons as individuals, taking into account their
views, cultural beliefs and practices, and not making assumptions. They have varying experiences, needs and
aspirations, they do not consist on homogeneous groups, and therefore our interventions cannot be replicable, but
adjusted.
2. Key concepts and definitions related to Migration

The following concepts have been extracted mainly from Background Paper on Migration (OCBA, 2009), and Briefing
Paper on Human Trafficking (OCBA, 2011). Professionals working with migrants in different disciplines should
understand accurately this terminology.
Migrants:
There is no comprehensive and universally accepted definition of who is a migrant. Generally speaking, a migrant is a
1
person who moves from one place to another to live, and usually to work, either temporarily or permanently. Migrants
leave for a variety of reasons. They may be forced to leave due to lack of basic needs, or in order to ensure the safety
and security of themselves and their families, but may also voluntarily decide to move for economic reasons, or to be
reunited with family members. Many leave for a combination of reasons.
When referring to migrants that are already in a place of destination, sometimes it is used the term immigrants.
Migrant Workers:
A migrant worker is defined in the International Migrant Workers Convention as a person who is to be engaged, is
2.
engaged or has been engaged in a remunerated activity in a State of which he or she is not a national
Irregular Migrants:
Irregular migration is complex and diverse concept, as irregularity can arise in a number of ways. Migrants may enter a
country without valid visas, by avoiding border controls or with false documents. Others enter legally but overstay their
visas and become irregular or may enter with a non-working visa, then work, thus breaching national laws. Irregular
migrants also include asylum seekers who stay on after their claim has been denied or victims of trafficking or
3
smuggling.
Irregular migrants are frequently referred to as illegal in public discourse. This is being criticized by international
governmental organizations and NGOs, as it criminalizes irregular migrants and denies their basic human rights and
4
dignity. Regardless of their status, migrants are entitled to protection under international and national law.
Sometimes the term undocumented migrants is also used to refer to irregular migrants.
Amnesty International, Living in the Shadows: A primer on the human rights of migrants, 2006, p. 5, see www.amnesty.org
Migrant Workers Convention, 1990. Part 1. Art 2(1)
3
Council of Europe, Commissioner for Human Rights, The Human Rights of Irregular Migrants in Europe, 2007, p. 3. Amnesty
International, 2006, p. 5. Global Commission on International Migration, 2005, Irregular Migration, State Security and Human Security, p.
4-7.
4
Global Commission on International Migration, Migration in an Interconnected World: New Direction for Action, 2005, p. 55.
2
Refugees:
According to the UN 1951 Convention Relating to the Status of Refugees, a refugee is a person forced to flee his/her
country because of a well-founded fear of persecution for reasons of race, religion, nationality, membership of a
particular social group, or political opinion and is unable or unwilling to avail himself of the protection in his/her home
country (Art. 1, UN 1951 Convention Relating to the Status of Refugees).
A key part of refugee law is the principle of non-refoulement, which protects refugees from forcible return to a country
where their life or freedom would be threatened (Art 33). Broadly based on the principle that refugees should have the
same rights as other foreigners who are legal residents in the country, the Conventions list a number of rights,
including non-discrimination, the right to work, housing, education, freedom of religion, the right to assistance and to
freedom of movement.
Asylum-seekers:
Asylum-seekers are persons who have reached another country and have submitted or will submit claims for refugee
status; they have not been formally recognized as refugee. The right to ask for international protection is recognized in
the Universal Declaration of Human Rights which states that: Everyone has the right to seek and enjoy in other
countries asylum from persecution. Art 14 (1).
As asylum determination procedures and, if the decision is negative, appeal may take years, asylum-seekers frequently
face situations of uncertainty and precarious living conditions.
Internally Displaced Persons (IDPs):

Internally Displaced Persons (IDPS) are persons or groups of persons who have been forced or obliged to flee or to
leave their homes or places of habitual residence, in particular as a result of or in order to avoid the effects of armed
conflict, situations of generalised violence, violations of human rights or natural or human-made disasters, and who
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have not crossed an internationally recognised State border.
IDPs retain the same protection as other citizens in their country and, legally, do not enjoy special protection, as there
is no international treaty or law specifically covering them. IDPs are often at greater risk than refugees, as they are
more likely to remain close to combat zones, in areas where there is no legitimate authority, or under the control of
the political entity oppressing them.
The Guiding Principles on Internal Displacement (GPID, 1998) set out guidelines for state authorities and the
international community to ensure that the rights of IDPs are protected. These principles are not binding in themselves
but, as they are derived from existing international law, are increasingly used in the field.
Human Trafficking:
According to Article 3 of the United Nations Protocol to Prevent, Suppress and Punish Trafficking in Persons, especially
Women and Children human trafficking is defined as follows:
(a) Trafficking in persons shall mean the recruitment, transportation, transfer, harbouring or receipt of
persons, by means of the threat or use of force or other forms of coercion, of abduction, of fraud, of
deception, of the abuse of power or of a position of vulnerability or of the giving or receiving of payments or
benefits to achieve the consent of a person having control over another person, for the purpose of
exploitation. Exploitation shall include, at a minimum, the exploitation of the prostitution of others or other
forms of sexual exploitation, forced labour or services, slavery or practices similar to slavery, servitude or the
removal of organs;
(b) The consent of a victim of trafficking in persons to the intended exploitation set forth in subparagraph (a)
of this practice shall be irrelevant where any of the means set forth in subparagraph (a) have been used;
(c) The recruitment, transportation, transfer, harbouring or receipt of a child for the purpose of exploitation
shall be considered trafficking in persons even if this does not involve any of the means set forth in
subparagraph (a) of this article;
(d) Child shall mean any person under eighteen years of age.
Migrant smuggling:
Defined in Article 3 of the UN Protocol Against the Smuggling of Migrants by Land, Sea and Air as The procurement in
order to obtain direct or indirectly, a financial or other material benefit of the illegal entry of a person into a State Party
of which the person is not a national or a permanent resident.
The Guiding Principles on Internal Displacement, 1998, Introduction, paragraph2.

http://www.brookings.edu/fp/projects/idp/resources/GPEnglish.pdf
3
Differences between Human Trafficking and Smuggling:

The first difference between human trafficking and migrant smuggling is the final outcome of the journey. Irregular
migrants often need to use the services of a smuggler against payment of a fee in order to enter a State without the
necessary documents. This fee may be exorbitant and the journey may involve numerous hazards but once they arrive
at their destination, smuggled migrants are free and their relationship with the smuggler comes to an end. In contrast,
trafficked persons are not free upon arrival at their destination. They are kept by the trafficker in an ongoing
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exploitative and abusive relationship.
The second difference is the issue of coercion versus consent. Smuggled migrants consent to pay the smuggler in order
to reach their destination, while trafficked persons are usually deceived into their situation of exploitation. They often
have been promised a well-paid job or better education. However, once they arrive at their final destination, they are
7
coerced to work in exploitative conditions they did not agree to.
The third difference is that human smuggling always involves border crossing, while human trafficking can take place
within the same territory. Trafficking can be international, when people are taken between different countries or it can
be internal, when people from rural areas and small towns are taken for sexual exploitation to major cities or high
transit border areas.
In practice, these differences between migrant smuggling and human trafficking shall not affect the kind the
humanitarian aid or medical care provided to a victim. However, since protection granted by states is based on legal
categories, the distinction between migrant smuggling and human trafficking could determine the referral options
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available for aid workers.
The distinction between the terms defined in this chapter is however getting more and more difficult, as the reasons
which motivate people to leave are frequently mixed (i.e., conflict or persecution together with poverty). Also forced
and voluntary migrants increasingly move alongside each other, using the same routes and means of transport. Lacking
safe and legal alternatives, they are sometimes forced to use the services of smugglers and often face violations of
their human rights in transit and or countries of destination.
In order to simplify the terms along the document, unless there is a need to determine an specific target group, the
term migrant will be used indistinctly to represent mobile population (immigrants, undocumented migrants, irregular
migrants, migrant workers, asylum seekers, unrecognized refugees), and at all stages of the migration process (predeparture, during transit and once in the reception community).
3. The context of Migration

Migration has been a constant feature of human history. However, with growing disparities between the North and the
South and greater mobility in terms of facilities for travel, an increasing number of people now try to escape conflict,
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violence, economic hardship and environmental disasters .
Variables that would influence the migration process (which could be either protective or risk factors):
Personal factors: age, gender, education level, health status, physical problems, previous disorders,
dysfunctional family, family responsibilities, low self-esteem, coping style, etc.
Cultural factors: cultural distance, language, religion, etc.
Social, legal and working factors: scarce and irregular social support, previous status, (un)employment, debts
in the place of origin, attitudes of reception community, etc.
Travel conditions: planned migration, victim of trafficking, fleeing due to disaster, etc.
According to life events before departure, we can find some who have been detained and tortured in their own
communities and who have been exposed to other types of violence. Some persons have been persecuted because of
their political or religion beliefs and activities, others because they belong to a minority ethnic group, or due to their
gender or sexual orientation. Some have had to leave because of environmental disasters or an engineering project.
Many people migrate due to poverty as disparities between rich and poor, both between and within countries continue
UNODC, 2006, p. XV, ASI: 2005, p. 6.
ASI, 2005, p. 6
Zimmerman: 2009, p. 9.
MSF OCBA, 2009. Background paper on Migration
to widen. Those leaving their country to seek asylum experience many looses: family members through death or
separation, home, friends, money, job, identity, dignity, hope, role, status and usual support network. These multiple
looses usually make their condition to be difficult to cope with. This phenomenon is usually named migratory grief.
Additionally, during migration, many other experiences are likely to be occurring: persecution, different ways of
violence, human trafficking, smuggling, witnessing violence and death, threats, etc.
As much as the main areas which determine the migrants current situation (housing, employment, health, education,
community relations, and legal status) are covered, their coping will be facilitated.
4. MHPSS consequences of Migration

The psychological condition of the migrant will be very much affected by the previous conditions and precipitating
events, the migration process with possible multiple and chronic stressors (including traumatic events), migration
looses (migratory grief), his/her own vulnerability to distress and his/her own inner and external resources.
Inner and external resources include resilience, strong personality, self-esteem, tolerance to frustration, tenacity,
empowerment, autonomy, type of locus of control (internal vs. external), other personal skills, the believe that there
are more benefits of having migrated, need to establish vital projects in the new place, belonging to a group, other
types of social support, favouring situations, etc.
The various stages of the migration process carry with them specific risk factors which can lead to increased
vulnerability to mental health difficulties.
Stages of Migration and Factors Linked to Psychological Distress10

The phases of migration, interlinked with significant life events and chronic ongoing difficulties, as well as personal and
relational factors must be considered separately and continually. In the first phase the psychological distress will be
different from that experienced in the last phase:
Possible Vulnerability
Factors
Stages
Personal Factors
Relational Factors
Personality
PRE-MIGRATION
Age, Gender, Reason,

Preparation, Personality,
Separation
Economic, social, educational
MIGRATION
Personal adaptation/attitudes
towards the migration process
Loss
Bereavement
PTSD
Cultural Shock
Assimilation
(Transit)
MIGRATION
AT PLACE OF DESTINATION
Aculturation
Support, Alone / Group

Social Support, network,
cultural identity, self-esteem,
self-concept
Educational, expectations,
language
Achievements, racism, ethnic
density, social isolation,
unemployment
Deculturation
Immigrant assimilation is a complex process in which an immigrant fully integrates into a new culture; it explains the
process of acquiring new customs and attitudes through contact and communication. The transfer of customs is not
simply a one-way process. Each group of immigrants contributes some of its own cultural traits to its new society.
Assimilation usually involves a gradual change and takes place in varying degrees; full assimilation occurs when new
members of a society become indistinguishable from older members.
10
Based on Bhugra & Jones, 2001

11
Acculturation explains the process of cultural change happening when two or more cultural groups enter in contact .
12
The adjustment effort implied is known as Acculturative Stress .
Deculturation is the loss of all own cultural reference values, without assimilating from other cultures, as a
consequence of migration.
Psychological reactions of migrants

The psychological reactions of migrants depend on a variety of factors:
The individuals personal history, past events
The atrocities and multiple losses that the person has experienced during migration
Present personal situation, including fears and uncertainties (such as being sent home)
Loss of friends, family, community, home, job, culture and country
Social isolation, poverty, hostility, loss of status, racisms, etc.
History or present mental illness, which may be long-standing or which may be linked with the experiences
Psychological distress is common in migrants. Persons commonly experience:
> Fear
> Extreme sadness, easy crying, feeling helplessness, depression
> Anxiety and panic attacks
> Problems with memory, concentration and disorientation, trying not to think
> Poor sleeping patterns, nightmares (of psychological origin and not conditions evoked when for instance
overcrowdings in detention cells)
> Repressed aggressiveness
> Psychosomatic complaints: headache / migraine (so-called im-migraine), muscular tension, palpitations
> Psychotic manifestations
As many migrants have gone through situations of violence and torture, it is worth to remind the most common
conditions and symptoms after these events:
> Anxiety; e.g. acute stress
> Hyper-arousal
> Loss and bereavement
> Shattered core beliefs
> Guilt and shame
> Intrusions
> Avoidance
> Low mood
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Main difficulties and concerns by migrants :

Isolation and cultural bereavement
Boredom or confounding of expectations of life anxiety, about migration status, financial worries and a
feeling of not being wanted in host community
Changing roles in the family or clash of values
Residual effects of traumatic events (although not frequently mentioned, need to be considered)
Physical illness
Risk of substance abuse, connected with worry, sleeping difficulties or boredom
Suicidal risk
Tendencies to engage in criminal activities (e.g. theft, threats etc)
In any case, expressions of distress and the ways in which persons cope differ from one individual to another one, even
with similar experiences, and between and within cultures, which makes the subject to be very complex. Particularly,
11
12
13
Moyerman & Forman, 1992

Berry & Kim, 1988; Padilla, Olmedo & Loya, 1982
Thomson, K. Waltham Forest Refugee Mental Health Project
every culture has its one framework for mental health and for seeking help in a crisis, but individuals may exhibit
different degrees of resilience and vulnerability.
Symptoms which may need specialist help include:
> Consistent failure to function properly with daily tasks
> Frequently expressed suicidal ideas or plans
> Social withdrawal and self-neglect
> Behaviour or talk that is abnormal, atypical or strange within the persons own culture
> Aggression
There is still an open debate about the connection between the migratory process and the development of
psychopathologic problems. But it is acknowledge that the migration process, the culture and the belonging to a
minority group influence mental health. The migration stress-related, cultural differences and perceived discrimination
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are considered risk factors .
According to DSM-IV-TR Acculturation problems (V62.4 / Z60.3) may be a focus of clinical attention. This problem
involves adjustment to a different culture (e.g. following migration).
Psychiatric diagnoses and labelling

There are two divergent perspectives related to psychiatric diagnoses, particularly the diagnoses of trauma-related
symptoms. One view is that by offering someone a diagnosis of a recognized condition, it permits that person to feel
less isolated or singular (i.e., abnormal or to blame) in terms of psychological experience. For some individuals, to
receive a recognized diagnosis removes some of the burden of guilt or frustration about feelings and behaviour over
which they have little control. Basically, people can become ill from undergoing severe trauma, not only physically, but
also mentally and both need equal attention. And, from a practical viewpoint, in some countries the receipt of a
recognized medical diagnosis enables an individual to access much-needed public resources.
From another perspective, by treating what are often understood as normal reactions to abnormal circumstances as
pathological conditions; individuals may feel or actually be stigmatized in the short or long term. This can lead to
misleading self-assessments, misconstrued identity and to marginalization if the individual is perceived as abnormal,
unreliable or incapable of functioning like others.
According to our approach, diagnosis enables to understand a condition; and as a medical organization we use
diagnostic labels, but always taking much into account clinical criteria including the length of the presentation of
symptoms (which is a crucial issue in stress and trauma-related conditions) as well as external factors such as the
context, unmet basic needs, etc. (which should be very much considered for some disorders such as Adjustment
Disorder. We consider very important to take care of over-diagnosing and pathologising conditions that are still in the
phase of being normal or natural expressions of grief and distress to abnormal situations. Furthermore, cultural and
social background clearly influences the way how people are reacting and presenting symptoms; therefore, standard
clinical criteria such as DSM based on western societies are not always applicable to other cultures. PTSD for nonwestern population in not necessarily culturally adjusted but however over-diagnosed. It is essential not to forget the
reframing on some conditions into understandable suffering. Additionally, cultural differences and difficulties with
language and communication may increase the possibility of a misdiagnosis of mental illness. All this is just to
emphasize that although we use diagnosis in our interventions, considering the contexts and the population with
whom we work; diagnosing becomes a very sensitive and complex issue.
Mental illness carries marked stigma in many cultures, which may prevent a person from seeking help. Culture affects
interpretation of behaviour and may influence diagnosis of mental illness.
The Migratory Grief, specific term to define the already mentioned losses that migrants are going through can be
helpful in the assessment and care of migrants in all stages. Achotegui, in 2002 developed the conceptualization of the
Ulysses Syndrome or Immigrant syndrome with chronic and multiple stress, to refer to the condition of the migrant
who suffers some specific stressors and grieves and some psychiatric symptoms from different psychopathological
areas. This is a condition more accurate to use for migrants already in the place of destination (see chapter 9). It is
14
Collazos et al., 2008
important to remark that usually the syndrome disappears when living conditions are normalized (housing,
employment, studies, etc.)
5. General Approach in MHPSS with Migrant Population

Working with migrants necessarily means assuming a global integrated bio-psycho-social approach. Particularly, taking
a psychosocial approach implies a link between social and cultural factors and the functioning of mental well-being.
This means, that to understand the functioning of the individual, s/he must be seen within his or her context, whether
that includes the family, community or culture. A psychosocial approach also implies that the mental well-being of an
individual or a group can be affected by acting on the social factors surrounding them.
MHPSS should be adjusted to the specific context and person, which often depends on the resources available and the
particular local customs and culture (experiential frames, health beliefs, perception of disease and health, need and
health seeking behaviour, etc.), that we should try to find out in a previous stage of assessment. To be effective,
support strategies should be adapted to an individuals needs, situation (e.g., other sources of available support,
duration of stay, etc.), personal profile (i.e., age, gender, culture, etc.) and personality.
Assistance, therefore should also be holistic, recognizing the multi-dimensional nature of mental health (i.e., physical
health, social and economic well-being), and offering multi-faceted forms of support (e.g., emotional, education,
employment). Working in mental health without basic needs covered would not be in principle recommended.
MHPSS activities with migrants are very much related to dignity-saving as a core dimension for human being.
Recovering dignity could be the essential focus of the intervention, when required.
For many people, also the restoration of their normal life as far as possible can be the most effective promoter of
mental health and can be much to relieve feelings of sadness, anxiety, etc.
MHPS Challenges in Migratory process:
a) Elaborate grief and losses
b) Facing stressful situations (multiple, chronic, intense, significant stress, absence of locus self-control
perception)
c) Acculturate Stress: healthy adjustment to new culture
d) Building a new identity: sense of self to be able to answer to the philosophical question of who am I.
Recovery is an individual process. As noted above, many factors influence an individuals resilience and ability to
readapt to the surrounding world in healthy ways (e.g., severity and duration of trauma, personal traits, quality of
support, etc.).
Regarding target population, all migrants in a situation of social exclusion and socio-economic vulnerability could be
the focus of our interventions. The specific target population in a project will lead with encountered needs always
following vulnerability criteria. Some examples of beneficiaries according to different criteria:
Legal status of migrants: generally our target population will include undocumented or irregular migrants,
asylum seeker, refugees, etc.
Age group: most of the time there would not be exclusion by age group; however a specific group such as
unaccompanied minors could be targeted.
Gender: could be or not a criterion; however most of the time due to their specific condition as migrants,
women and children could be defined as the most vulnerable.
Exposure to violence: e.g. victims of torture, SGBV survivors, victims of human trafficking
Some general principles of MHPSS interventions have been identified while assisting people who have experienced
traumatic events:
Establishment of safety, and restoration of power and self-control, including control over their body, their
emotions, thoughts and their environment. Progress will be difficult until the individual feels secure.
Remembrance and mourning. In theory, this occurs when traumatized persons recount the story of what
happened to them and grieve over what they have lost (both psychologically and physically). The choice
whether to face the details of the terrifying past, how and when should always be left to the individual.
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Reconnection with ordinary life. The process of integrating or reintegrating into society/community and
developing or redeveloping relations with others. This process can take a long time. For many it can take a
lifetime. Psychosocial support that includes educational, occupational and economic aspects is an integral part
of an individuals progress. And for that we need the collaboration of other organizations or institutions
involved in other areas.
Common features of MHPSS effective responses to trauma include:
Avoiding victim-blame;
Supportive environment (community, medical team etc);
Recognizing abuses as criminal victimization;
Providing information about traumatic reactions, and
Showing expectation that symptoms will improve.
Some examples of strengthening resources that can be useful working with migrants:
Creating active listening spaces
Information and orientation. E.g. regarding the lack of comprehension and uncertainty of psychosocial
complaints; the fear not to be able to continue tolerating the facing of all doors being closed
Facilitating spaces for interchange of concerns and enlarging networks
Considering them as individuals with a need of ownership and social recognition, rather than with economical
and working needs
Protecting cultural heritage without leaving aside the adjustment resources
Training them in social skills (e.g. communication, assertiveness, adaptation skills etc), sleeping hygiene, and
other practical needs.
Giving them as much control over the path and content of the interventions
As well as in other contexts, but very important here: sensitization of all professionals of the importance of
community processes to inform, orient; the importance of empathy, to observe risk factors and
symptomatology of some migrants, differences; in order to give good orientations
Testimony: many persons wish to review and communicate their experiences and find this process to be
therapeutic; however, not everyone needs nor wants to do this and some find telling their stories extremely
distressing. However, we need to stress out that MHPSS sessions are not a testimony collection session.
Social support, reducing their isolation and accessing help with practical and social issues may help mood for
many people.
It is important not to assume that western or modern psychological models are the only or the highest standard of
response to psychological distress. While mental health and psychosocial support can take the form of sessions with a
psychotherapist or counsellor, it can equally well include participation in community empowerment or development
projects, participation in training, education or cultural orientation programmes, taking on a job or building new
relationships or redeveloping existing ones.
Being ready for all kinds of emergencies should also be part of our intervention strategies, giving equal attention to
regular activities, without forgetting them. Contingency plans are very much recommended.
Initial Assessment
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Before starting an intervention an in-depth assessment should be performed . The key information that should be
obtained during the exploratory should be:
16
Exposure of the population to specific traumatic events
Level of disruption of family and community network: how much the migration has impacted change in
familiar roles, dynamics, etc.
Health care data mainly regarding: morbidity diagnosis which could be partially explained by MH and if there
are changes in prevalence (e.g. generalized body pain, gastro-intestinal complaints, sleeping problems,
headache) and MH disorders statistics of the target population (if any).
Beneficiaries perspectives on the psychosocial consequences of violence, disaster, displacement,
15
See Recommendations for assessment and planning mental health and psychosocial interventions in emergencies, MSF OCB, 2009, or for non
MH professionals: Guidance for brief mental health assessment by field team, MSF OCB, 2009.
16
Such as armed attack, bombings, executions, torture, sexual assault, physical assault, landmines, abduction, imprisonment, destruction of home
and properties, displacement, refuge, migration, natural disasters, nutritional crisis, etc.
etc. (How do people understand and deal with psychological consequences such as trauma?):
- Health and Functioning (health seeking behaviour, health beliefs, local ways of thinking, opinions,
perceptions and suggestions)
- Ways of expressing emotional distress and vocabulary used
- Individual psychosocial self-help (coping) mechanisms
- Sources of relief and support in the community
Existing services and resources for MHPSS: MoH level, other medical services, local & international NGOs,
other traditional services:
- Local and/or international organizations providing MHPSS (psychological, psychosocial, counselling,
etc.), and which kind of service
- MH professionals in the country/region available: trained MH counsellors, psychologists,
psychotherapists, psychiatrists, psychiatric nurses, etc.
- Essential psychotropic drug list available; GP are able to prescribe?
- Staff trained to provide psychological first aid (PFA)
- Womens or other networks
Regarding methodology, the main instruments are commonly used are compilation of data, individual semi-structured
interviews, structured observation, key informants interviews, participatory mapping, validation of information and
triangulation of data, group discussions, focus groups and other creative methods. Particularly, when using focus
groups, given the sensitiveness of the problematic, some aspects to be taken into account:
Tensions between homogeneity and heterogeneity
Differences between focus group discussions, group discussions and self-help groups
Importance of confidentiality
Minimum of four groups per population group
Attention to socially expected answer (positive and negative falsies)
Gender balance (since in some cultural contexts male participants tend to overshadow the opinions of female
ones)
In order to structure in a simple way the suggested MHPSS interventions with migrants, we would consider: Mental
Health promotion and Psycho-education (I), Individual and Group counselling and therapy (II), community interventions
(III), social and recreational activities (IV) and Awareness and Training to Health, Social and Education professionals (V).
Networking, coordination and organizational issues are considered as transversal and to be shared with other
components of projects.
I. Mental Health Promotion and Psycho-education

Psycho-education activities can be run in health facilities, mobile clinics or in communitarian settings, according to the
context. Ideally, health promotion activities will be addressed in an integrative way; for instance, sessions addressing
violence situations and services would be more comprehensive including physical, mental and social aspects.
In most situations, and mainly when it is considered unlike to have the possibility to meet the same group more than
once, it is necessary to do a group brainstorm and decide the subjects which should be prioritized (e.g. violence or
general well-being or psychosocial adjustment).
The subjects to be tackled should be interesting for those migrants. Sometimes if we believe that there is a subject that
in terms of health is very sensitive (e.g. Sexual violence) and supposes a risk for that community, finding an attractive
way of addressing the topic could help to encourage interest.
When possible and adequate, the sessions would include explanations about the link between the lived experiences,
consequences, and possible physical and psychological reactions and expected ones, provide access to information
about positive coping mechanisms, and available resources (medical, psychological, social, legal).
Sometimes meetings and gatherings will be complemented with distribution of leaflets and posters, and use of
flipcharts.
In some situations the use of mass media for psycho-education purposes can be considered, through radio messages,
participation into programmes, messages and articles in press media, etc.
10
II. Individual & Group Counselling and Therapy

Counselling sessions can also be conducted in health facilities, centres, and associations or punctually in the
community.
Clear criteria establishing the responsibilities of specific professionals that would be in charge of each activity must be
well assessed and determined (psychologists, counsellors, psychiatrists; considering their gender and other relevant
factors)
The choice whether to start group counselling interventions would also depend on the context and practical
possibilities. For instance, with victims of human trafficking it would not be recommended in principle to use group
counselling while they are in the network, unless a minimum of confidentiality is ensured; as it is not enough safe for
themselves.
Different types of group can be organized. An open group based on a specific subject such as violence or grief can be
offered to a group of women. Otherwise, a group of persons presenting a specific clinical condition could form a close
group to be followed by the same patients and with a more strict commitment.
While the past may have caused much of a migrants current trauma, approaches to support should not consider past
experiences and related memories only, but also help the individual to advance confidently towards a healthy and
promising future based on his/her prospective life plans.
Play and art therapies and creative arts (art, dance movement, drama, acting, games, sports, music, writing, poetry,
painting, etc.) offer a variety of different channels of communication in which to engage with psychological issues. They
can be used for instance for working with isolation, community meaning, self-esteem, strengthening identity and the
sense of owning and belonging, etc. It can be very beneficial to combine a psychological framework with the creative
dimension of art forms.
Factors to consider in assessing the mental health of migrants:
Patients explanatory models and attitudes towards illness and health
Cultural identity and cultural conflict
Ethnic density
Migration status
Experiences of migration and migration phase
The host societies attitudes
Adjustment
Achievements and expectations
+ All classical factors (history of disorders, etc.)
Individual coping strategies can be divided into problem-focused vs. person-focused and individual vs. social. Problemfocused strategies address the circumstances presenting difficulties, while Person-focused aim to find means of
adjustment to those circumstances. Individual strategies involve individual acts or analyses, while social are more
focused on shared acts, community involvement, etc. Working with migrants would ideally mean to strengthen a bit all
kind of strategies; however it should be assessed according to the specific needs. Social strategies would be for
instance very useful for practical assistance than focusing on emotional well-being.
Some specific recommendations regarding individual interventions:
Each project should elaborate specific criteria to determine the type of intervention according to needs and
real possibilities assessed mostly during first approach or session with the person. Example:
17
a) Psychological First Aid : for individuals presenting acute suffering, in order to give immediate
support. However, when possible follow-up sessions will be conducted.
18
b) Single session : when it will be unlikely to do follow-up or there is no further need of individual
support.
c) Individual Counselling or Brief Psychotherapy (specifying criteria)
17
See Psychological First Aid: Field Operations Guide by National Child Traumatic Stress Network & National Centre for PTSD, 2006. WHO is
currently developing also a guideline for Psychological First Aid.
18
Refer to Document for guiding decision-making & implementation for Mental Health and Psychosocial single session. MSF-OCBA, 2011.
11
Persons who have experienced situation of violence or torture might feel relief when being questioned about
their experiences, but if direct questioning appears to be uncomfortable, the subject may be introduced
indirectly. E.g. I know that some people in your situation have experienced torture and violence. This is
something that I may be able to help with. Has this ever happened to you?
Individual counselling or brief psychotherapy is better done when the patient is feeling a minimum of safety.
When this is not the case, it may be better to focus on improving his/her social situation (if possible) and
strengthening coping skills to help with distressing memories and present acute suffering. If addressing those
memories it is important that the patient feels in control of the process.
Keep checking whether the pace and content used in a session is comfortable for the person.
Be very careful assessing the themes and therapeutic elements so they are adequate for the person in that
specific moment of life. For example, sometimes using negation as a defence related to a harmful current
situation makes the person protected and courageous to achieve an objective.
Migrants can be very much concentrated in their suffering, surrounded by horrendous conditions, unmet basic
needs and therefore the person feels not able to share at all or at least from the past. This can be also
protective, but leaves sometimes a limited leeway. Nevertheless when overcoming very stressful situations
after many efforts, it can be an entry door for the global process of recovery.
Transference and counter-transference issues are important to take into account. Possible prejudices, stigmas
and pre-conceptions by both the counsellor and the patient towards the other could interfere the process.
Therapeutic objectives would not be world-wide accepted. E.g. socially expected values such as
individualization and separation from nuclear family for a young person would not be considered depending
on the culture.
About internal referral criteria from doctors, nurses to psychologists/counsellors.
From the point of view of the counsellor or psychotherapist working in a trans-cultural setting, it is of utmost
19
importance :
The sensitiveness of the counsellor towards cultural differences and towards its own bias
Gaps in counsellors/therapists knowledge of the culture of the person in consultation
Counsellors skills and commitment to develop a close professional relationship which reflects the cultural
needs of patients
Counsellors skills to face the increasing complexity when working trans-culturally
Decisions regarding treatment strategies should be guided by the migrant persons desire to participate and duration of
stay. Other factors to consider include:
Treatment goals (e.g., functional improvement, addressing severe disruptive behaviour or co-morbid
disorders)
Co-morbidity (presence of pre-existing disorders, serious pathologies)
Substance/alcohol abuse or dependence
Severity of mental health problems, e.g., risk to self, others, ability to take care of oneself
Concurrent medical conditions.
Competencies of psychologist/counsellor
Possibility for follow-up sessions
Persons understanding of basic concepts, e.g. feeling, thought, emotion, mental health, psychological pain etc
Regarding Certificates, it should be appointed that MSF would issue certificates according to the regulations of the
country, but also the importance of confidentiality, the use of it and the general implication for staff and MSF.
III. Community interventions/IEC

Community interventions will vary also according to the context. For example, in situation of migrants in transit, a
counsellor or a health worker will approach the places of settlement to meet the population and explain about MSF
and or other services, to invite them for other activities or to perform a group with them. It could also happen that a
counsellor decides to do a psychological first aid session at the place, searching for minimum of privacy and
confidentiality. Another example would be in a situation of human trafficking, where our first contact will probably be
with the chairman of the network, to whom we will introduce also the organization and offer our services, which will
most likely happen somewhere else.
19
Konrad & Santonja, 2003
12
In some cases community interventions will also have the aim of screening those migrant who are in more suffering to
offer them specialized care. Criteria should be clearly defined in advance, following current guidelines.
Group Discussions (not focus group) are likely to be happening at communities. It can be a very helpful way to start
contact with migrants, addressing a subject, and leaving them the opportunity to express themselves. It has also the
added value of encouraging trust and confidence towards the professionals, and it also helps to better understand their
needs, their cultural features, their interests, etc, and thus better define and adjust activities for them. Additionally it is
a way to screen persons in need. These activities should be dynamized with much care, trying to limit personal
implications and emotional discharge. It is important to emphasize that group discussions are not the same as group
counselling.
Community mobilization and local capacity building, when possible will be more than suggested, with existing groups
or searching for link/resource persons. Sometimes this will be achieved through networking, rather than being part of
our programme. Other times, identifying a skilled migrant to be trained as peer counsellor could have a double goal: a
community and individual impact but also improving our programme.
IV. Social and Recreational Activities

In addition to formally structured activities, ad hoc meetings between migrant persons, during which they can speak
Informally and share their feelings and concerns, have important therapeutic benefits.
Group work can offer support and reduce isolation. Care and understanding from those who are closest to them
(family, friends and community) are the most important factor in promoting resilience. Mental health problems
resulting from migration are often enduring, and the best support is the one available for long-term and at times when
the individual experiences difficult periods. However, even when individuals are in the very brief care of an assistance
intervention (either because they are repatriated or because they are in transit, etc.) it is possible to provide
psychosocial support.
Examples of social and recreational activities:
Story telling and narrative
Art, painting, music, poetry
Relaxation and breathing exercises
Dance, drama
Sports
Open-air games
Crafts workshops
Hair-dressing, cosmetics, cooking, sewing, knitting workshops.
Studying languages
Some of these activities, as we have seen before, can be also used in counselling and therapy. However, the main
difference is that when being designed as recreational or social activities they do not require a specific therapeutic
objective behind, but just the principle of contributing to the general individual and social well-being.
V. Awareness and Training to Health, Social and Education professionals

In the level of Primary Health Care, health workers should use supportive and active listening in order to acknowledge
injustice, both past and present and to help people to cope both with their memories and with their current situation.
Many people find that talking helps, as bearing of testimony. However, some people may be suspicious of health
workers. Trust needs to be gained and may take some time to develop. In addition many people may experience guilt
or shame regarding their experiences.
Formal trainings such as screening and identification of mental health cases, psychological first aid, as well as other
more informal methods, info-sessions, case discussions, etc., could be used with other professionals according to the
goals established.
General considerations related to interventions

Exit Strategy should be in place from the very beginning.
13
Ensuring a Referral System with other professionals and services is required when establishing a project, with clear
referral criteria for services such as psychiatry, social work, primary health and others relevant.
It is important to be able to recognize those individuals whose mental health is severely impaired (either due to the
migration process or a pre-existing mental illness), and who require immediate specialized attention. In particular,
individuals who are at risk of harming themselves or others, or cannot take proper care of themselves due to their
mental state (e.g., do not get dressed, do not eat, present psychotic reactions, etc.) may need medication to stabilize
their condition, and, in some cases, may even need hospitalization. Therefore, to establish a correct diagnosis, it is
essential that a health practitioner who is trained in mental health see all migrants considered at more risk (e.g.,
victims of trafficking) who will be assisted by the service provider. Depending on the resources of the setting, this might
be a general practitioner with training in mental health, a psychiatrist, a clinical psychologist, a psychiatric nurse or a
social worker with psychiatric training. If individuals present serious impairments, these professionals must refer the
case to a specialist, or begin (medical) treatment.
Ethics and confidentiality are always key issues of MHPS work; and very particular with populations at risk or socially
neglected as migrants. Regular principles will be applicable here.
MPHS aspects are also much linked to protection. Within MSF projects we often face problems to find a proper actor to
address protection to our beneficiaries.
Advocacy activities can be an important component of the project with migrants; an important effort to determine the
link between the two components, the information sharing system, etc. should carefully be planned. Ethical principles
should be considered, but spaces for testimony, lobbying and sensitization tools can be facilitated.
6. Interventions with Migrants in Transit

Migrants advance in their journey to destination according to access from one country to another, obstacles, difficult
experiences, economical possibilities, services of smugglers, travelling with family, etc. Sometimes they will remain in a
place for a few hours or few days, and even weeks and months. For example, Nigerian migrants in Morocco can stay for
long time in the border with Algeria, waiting the chance to cross to Spain. In Mexico, near to the border with
Guatemala, Centre-Americans usually stay for a few days in albergues, hosted waiting for a freight train to continue
their trip to USA. Interventions as always will be adjusted to the specific population, vulnerable groups, length of stay,
identified needs, etc. Physically MSF can be working in other organizations facilities, health centres, MSF centres and in
the field, directly where communities are staying in their transit. Once again, security will be guiding very carefully the
strategies and extension of activities.
Dilemmas and concerns regarding the work with Migrants in Transit:
When migrants report incidents of verbal and/or physical violence by authorities, protection and safety of
patients cannot be ensured and the role of MSF towards these violations is not easy. Sometimes MSF can alert
and/or refer cases to other organizations such as UNHCR.
Individual counselling sessions, which are appropriate in western cultures, are not always corresponding with
the needs of the migrants, their contexts and cultures.
High turn-over of migrants and short length of stay makes difficult to maintain a trusting relationship between
professionals and migrants.
Trust-building strategies adjusted to the specific problematic.
Single individual sessions are not always the best option.
Difficulties to ensure external referrals and external follow-up (e.g. psychiatric cases).
Misuse of sessions by migrants to get more information about administrative or legal issues.
Minimum conditions of victims in order to benefit from psychosocial care
Security and safety as minimum requirements for a proper psychosocial care?
Real access to victims for psychosocial care vs. need to mask the activities.
Possibility of offered care different from demand.
Counselling as a risk in terms of setting up problems that where not consciously identified, opening
Pandoras box
14
Possibility of working in counselling without a first stage of setting problems? (In order to preserve
protection mechanisms already functioning and working in that specific period of life).
Cultural and Recreational activities as means of psychosocial wellbeing catalysts, even without complementary
psychosocial/mental health activities.
7. Interventions with Migrants in Detention Centres

By its nature, the practice of immigration detention represents a threat to key human rights principles: the right to
seek asylum; the right to be free from arbitrary arrest, detention or exile; freedom of movement; and the right to be
20
free from torture or cruel, inhuman or degrading treatment or punishment .
Mental Health research indicates that rates of mental disorder amongst population held in detention are substantially
higher than compatriots held in community settings. Children in particular show evidence of severe impairment. Rates
of suicide and self-harm have been documented as being many times higher than amongst prison population.
Prospective research document a pattern of deteriorating mental health as length of time in detention increases.
Studies surveying refugees released from detention suggest that the practice may result in prolonged mental health
impairment.
Collectively, the evidence from all sources suggests that immigration detention represents a major threat to the mental
health well-being of displaced populations in the short and long term.
Immigration detention provides a clear example of the intrinsic link between the denial of basic human rights and
deterioration in health and mental health in particular. Confinement, isolation, lack of freedom, perceptions of being
arbitrarily punished, uncertainty about the future, and fear of being returned or to situations of danger all converge to
create a pattern of deteriorating mental health that does not appear to be evident in community-based alternatives.
MHPSS is generally required in Detention Centres (DC) and Border Police Stations (BPS). However, a minimum of
conditions have to be met to implement this type of intervention in order to have a minimum sense and impact.
Based on MSFs experiences working in DC the following criteria for our interventions were proposed:
First key element to consider is the need to meet basic living conditions (minimum spaces in rooms, some yard
time, proper water and sanitation facilities, hygiene items, NFI, food, etc.).
Migrants are minimally informed of their status and their future, they have access to translation and to
asylum procedures
Clear needs assessment and previous context analysis
An independent evaluation of mental health and psychosocial needs
Limited in time and with clear objectives
Proximity to the target population
Temporary intervention with a clear exit strategy
Possibility of migrants and MSF to speak out
MH as an integrative component of medical care
Specific agreements on access and security issues with authorities, with clearly definition of terms of
collaboration (e.g. a working space available for consultations where privacy and control can be ensured) and
some degree of independent functioning in the DC and continuity in the programme
Prepare police officers towards the implementation of agreed terms and as much information as possible on
the nature of the organization, and the mental health, psychosocial activities and aims
Experienced staff able to deal with stressful situations and to adapt to a dynamic environment. Also providing
close guidance, supervision and support to staff.
Organize interventions mainly around group activities that strengthen the existing support systems among
migrants; as well as well defined individual strategies
Acknowledge the stress of people working with migrants, for example police officers in detention centres or
border police stations
20
Zachary Steel et al. Global Protection and the Health Impact of Migration Interception. PLoS Medicine series on Migration and Health. Vol. 8-2011.
15
Detention causes growing anxiety, fear and frustration and often increases underlying stress resulting from the journey
or in the country of origin or transit. In Belgium in 2006 for example, 21% of the people seen during our consultations
reported suffering physical abuse prior to arrival and many reported witnessing deaths of family members or cotravellers. More recently in Malta, an MSF psychological support project providing individual consultations with the
detainees revealed the mental health importance on detainees of the harsh journey to Malta and their subsequent
confinement in DC. One third (33%) of MSF patients reported the death of a family member as the most relevant event
in their past and 21% reported having been direct victims of physical violence prior to arriving in Malta. Psychological
distress among inmates is reflected in the high number of somatic complaints reported in medical consultations.
Suicide attempts, group breakouts, rioting and sporadic hunger strikes also point the high levels of distress.
Psychological problems reported among MSF patients included: symptoms of depression (30% in Malta and 26% in
Greece), Anxiety (25% in Malta and 28% in Greece), Post-Traumatic Stress Disorder- PTSD (9% in Malta and 11% in
Greece), Psychosomatic disturbances (5% in Malta). There is a direct link between the length of stay in detention and
the level of desperation reported. 16 out of 17 patients who revealed suicidal tendencies had been in the centres for
21
more than four months .
In terms of the specific MHPSS activities it is required to ensure a private counselling room (or shared but private), time
and space to do group therapies and possibilities to organize group sessions adjusted to identified needs.
Dilemmas and concerns regarding the work in Detention Centres:
Restoring peoples ability to make their own choices seem difficult, if not impossible, in a detention setting
where people are deprived of their freedom.
Often problems have to do with the fact of detention itself, therefore the role of the psychologist or
counsellor to help them adjust and tolerate the conditions of detention becomes paradoxical: ethical dilemma
related to the possible conception of MSF being perceived as supporting the system.
In a detention setting, which operates under the presence and control of police authorities, independence
could be questioned.
When migrants report incidents of verbal and/or physical violence by the police in the DC, protection and
safety of patients cannot be ensured and the role of MSF towards these violations is not easy. Sometimes MSF
can alert and/or refer cases to other organizations such as UNHCR.
High turn-over of migrants and short length of detention makes difficult to maintain a trusting relationship
between professionals and migrants.
Limits for the positive mid-term impact of the psychosocial care in this context.
Single individual sessions are not always the best option
Pandoras box
Possibility of working in counselling without a first stage of setting problems? (in order to preserve
8. Interventions with Migrants Victims of Trafficking

Psychological coercion and abuse are hallmarks of trafficking in persons, and are fundamental tactics used by
traffickers to manipulate individuals and effectively hold them hostage. Psychological control tactics include
intimidation and threats, lies and deception, emotional manipulation and the imposition of unsafe, unpredictable and
21
The impact on detention on migrants health. MSF Briefing Paper , 2010
16
uncontrollable events. Such psychological abuse is generally persistent and extreme, and frequently perpetrated in
such a way as to destroy an individuals psychological and physical defences. First, the individual is forced into extreme
survival conditions during which the possibility of death is made real and the individual realizes the loss of control over
personal safety and exposure to the trafficker. The second stage involves physical exhaustion. Individuals are forced
to work long hours and days, which gives owners significant control (and increased profits). With no time to rest, the
individual is debilitated and unable to consider any options or contemplate defence strategies. Control and isolation
are the final elements ensuring dependence. In a captor-captive situation, where the only substantial contact is with
the trafficker, the individuals perceptions of the world and oneself are a reflection of her/his skewed construction of
the universe.
Individuals who have been trafficked frequently encounter some form of substance abuse or misuse and may develop
chemical dependence. Drugs and alcohol are commonly used by traffickers in the abduction and/or control of
trafficked persons. Addictive substances are used not only to make individuals more compliant, but are frequently also
introduced to create a dependence that forces the addicted trafficked person to rely on the trafficker as their supplier.
Drugs may be used to make a woman who was forced into prostitution more submissive during her encounter with her
first client. Drugs, illegal or legal, may be consumed, by force or voluntarily, to enable individuals to work longer hours,
take on harder work (or more clients in the case of prostitution), endure abusive conditions and treatment, withstand
activities they find degrading or abhorrent or to help persons anaesthetize themselves against the trauma and stress of
the situation. Professionals working with trafficked persons must be aware of the reasons why individuals might
develop a chemical dependence, and understand the associated signs and symptoms. If a trafficked person discloses a
chemical dependence problem or a staff member suspects a problem, the individual should be referred to
appropriately trained medical staff.
Although every individual will respond differently to a trafficking experience, some common reactions may include:
Psychosomatic reactions:
> Aches, pains, headaches, neck pain, backaches, stomach aches, gastrointestinal problems
> Trembling, sweating, heart palpitations
> Unhealthy changes in sleep pattern or appetite
> Immune-suppression and related complications (e.g., increased susceptibility to colds, flu, etc.)
> Increased risk behaviour (e.g., smoking, alcohol, drugs, sexual risk taking).
Note: It is important not to assume that somatic complaints are always reactions to stress. Particularly because
trafficked persons are likely to have suffered physical hardship, or have been intentionally injured, physical
symptoms must be taken seriously and adequately assessed.
Psychological reactions:
> Fear of being alone, of being found and punished by the trafficker, of their family being punished and of the
consequences of being an illegal migrant
> Helplessness and lack of control
> Sense of hopelessness, lack in trust in themselves and those around them and despair, suicidal preoccupation
> Explosive or extremely uninhibited anger without apparent reasons; or anger that they have allowed this to
happen and that their lives are so destroyed
> Guilt that they have made such a mistake, become criminals, brought trouble to their families or broken
mores of traditional culture
> Feelings of betrayal by the traffickers, their own families and society
> Alteration in consciousness, including amnesia, transient dissociative episodes, reliving experiences
> Alteration in relations with others, including isolation and withdrawal, persistent distrust.
Note: It is not uncommon for persons who have been trafficked to show hostility and demonstrate aggressive
behaviour. It is important to fight the natural reaction to become angry, frustrated or to dismiss or reject the
person. Try to recall that these expressions are not personal.
Although many of the psychosomatic and psychological reactions mentioned above could be considered normal
reactions to an abnormal event (the trafficking situation, as for all traumatic experiences), these reactions should be
taken seriously as they can be the symptoms of a mental illness that needs special attention and care.
17
Some individuals may present serious forms of mental illness, such as mood disorders (mainly depression), anxiety
disorders, adjustment disorders, Post-Traumatic Stress Disorder, and psycho-active substance abuse disorders.
No blueprint exists for mental health support for trafficked persons. However, patterns of recovery and strategies for
assistance have been suggested by individuals in the field of mental health and professionals working with trauma
survivors. Ultimately, the goal of all psychological support for persons who have survived a trafficking experience is to
promote their ability to create a life for themselves beyond the trafficking situation.
Intervention strategies must be based upon an understanding of the psychological painful experience of the victims
and must focus on assisting the victims full recovery, when possible, and hopefully, according to the moment of the
intervention, to the re-establishment of a normal life.
Key elements for intervention with survivors already out of trafficking:
Restoring safety: unless a sense of safety is guaranteed, only partial achievements can be expected
Enhancing control: The trafficker has sought to take control away from his victim; in order to move forward,
strategies must seek to give people as much control over the recovery process as possible.
Restoring attachment and connections to others: the fundamental challenge for humanitarian workers is to
provide acts that are caring, that are giving and that are kind so that connections can be re-established and
victims can begin to realize that there are others in the community who will care for them.
Restoring meaning and sense of purpose, as well as personal dignity and self-respect.
Once the survivor is out of the trafficking network immediate crisis counselling, if required, should be followed by a
longer-term therapeutic intervention to address the needs of the victims, as they progress towards recovery. In the
case of children, psychological assessment and therapeutic interventions should be provided by childrens professionals
and should involve family members whenever possible.
The Victorian Foundation for Survivors of Torture in Australia provides the table below to illustrate these principles and
processes. While the table focuses specifically on survivors of torture, the elements and principles described provide a
useful model for programmes of assistance for victims of trafficking:
Causes of the trauma reaction, its core components and recovery goals:
(Victims Referral and Assistance Service, Melbourne, 1999)
Acts perpetrated by the
persecutory regime
Social and psychological

experiences that lead to
trauma reaction
Core components of the

trauma reactions
Recovery goals
Violence
Chronic fear
Anxiety
Restore safety
Killings
Chronic alarm
Feelings of Helplessness
Enhance control
Assault
Inescapability
Loss of control
Reduce Fear and anxiety
Disappearances
Unpredictability
Death
Disruption of connections to
family, friends, community
and cultural beliefs
Relationships changed
Restore attachment and

connections to others
Depression
Offer emotional support and

care
Destruction of values central

to human existence
Shattering of previously held

assumptions: loss of trust
meaning, identity and future
Restore meaning and purpose

of life
Humiliation and degradation
Guilt
Restore dignity and value
Shame
Reduce excessive shame and

guilt
Separation
Isolation
Grief
Prohibition of traditional
practices
Deprivation of human rights
Killing on mass scale
Exposure to boundless human
brutality
Invasion of personal
boundaries
Impossible choices
Supportive Responses to common reactions to trafficking in a service setting
18
(Source: C. Zimmerman, 2004, Trafficking in women: conceptualizing and measuring health risks and consequences,
PhD dissertation, Health Policy Unit, London School of Hygiene and Tropical Medicine, London.)
Common Reactions to
trafficking
How reactions may manifest themselves

in a service setting
Supportive responses to negative reactions
Fear, insecurity, anxiety
Reluctance to meet people, go outside or be

alone; trembling, shaking or heart racing;
difficulty sitting still or concentrating
Mistrust of others
Wariness of service provider and of offers of

assistance; reluctance to disclose information;
giving false information; difficulties in
relationships with support persons, coresidents, others in programme, family, etc.
Passivity, difficulty making decisions or trusting
ones decisions; difficulty planning for the
future; hyper-sensitivity or hyperresponsiveness to others and outside
influences
Difficulty making eye contact, difficulty in
expressing oneself; difficulty in disclosing
details of events and feelings; reluctance to
undergo physical examinations, to participate
in group or other forms of therapy
Hostility or violence towards support persons
or others (e.g. co-residents, family); selfinflicted physical harm; sabotaging her or his
own process of recovery; over-reacting;
unwillingness to participate; blaming or
accusatory towards others; uncooperative or
ungrateful responses
Inability to recall details or entire passages of
the past; altering accounts of past events;
seeming unwillingness to respond or to answer
questions
Sadness, depression, disengagement from
others and activities, lethargy, seeming selfabsorbed or self-centred; believing no one can
understand
Inability or reluctance to make decisions;
desire to please; easily influenced; inability to
assert self or personal preferences; regular
complaining; refusal or reluctance to accept
assistance
Implementation of security measures; description

and reassurance of security measures;
confidentiality, and security of physical venue;
accompaniment to outside appointments of errands
Patience and persistence in developing relationships;
unconditional provision of practical assistance and
moral support; regular inquiries into needs and wellbeing
Mistrust of self, low selfesteem
Self-blame, guilt, shame
Anger towards self or

others
Memory lapses,
dissociation
Isolation, loneliness
Dependence,
subservience, or
defensiveness
Creating small tasks, setting short-term goals,

fostering short-term accomplishments, validating
achievements
Reassurance that what happened was not her or his

fault, reminder that trafficking is a crime that
victimizes many people and that they are not alone;
reminder of her or his courage and resourcefulness
under extreme conditions
Patience; remaining calm in the face of hostility, not
reacting with anger, hostility or showing frustration;
implementation of reasonable and proportional
measures to ensure the persons safety;
implementation of reasonable and proportional
measures to ensure that safety of others
Not judging or condemning the person; not
pressuring or harassing the person; understanding
the importance of forgetting for some people
Offering phone contact (or other contact) with
family, friends, etc.; opportunities to participate in
one-to-one or group activities; planned tasks or
events
Assigning small tasks; setting limited goals;
reassuring the persons of their abilities and capacity,
not fostering dependence by assuming all
responsibility for the persons welfare (allowing
persons to choose when, how or if they wish to be
assisted)
In case that the person is still victim of trafficking the work that can be done is much more limited in terms of mid and
long-term impact. However, there are still modest objectives than can be worked and achieved.
Key elements for intervention with survivors still in situation of trafficking:
Giving the open space (ensuring confidentiality) to share with an external person about her feelings,
experiences, thoughts, expectations, etc., if conducted with much attention and keeping a minimum of
contention in order to not leave the person overwhelmed and not functional
Strengthening coping mechanisms to cope better with the situation
Restoring safety is not yet possible. Nevertheless if the victim accepts to meet a MH professional,
confidentiality and accompaniment in the process can relieve partially the charge of the lack of freedom and
uncertain environment.
Enhancing control: Sometimes a few strategies could be searched in order to give control to practical issues.
For instance, the victim sometimes can try to negotiate private times or spaces.
19
Restoring attachment and connections to others: the fundamental challenge for humanitarian workers still in
this case is to provide acts that are caring, that are giving and that are kind so that connections can be reestablished and victims can begin to realize that there are others in the community who will care for them.
A minimum of psychological work can be done about meaning and sense of purpose, as well as personal
dignity and self-respect. However, with much obstacles in their situation.
The extend of the individual work that can be done with victims depends on the starting point related to the
consciousness of his/her situation, her expectations, the limits (if any) that she has established that she would
not cross and her general mental health state.
Alternative spaces for social contact, recreation, etc.
22
Recommendations for individual meetings and consultations with trafficked women :

Do no harm: treat each woman and the situation as if the potential for harm is extreme until there is evidence
to the contrary. Do not take any approach or meeting that will make a womans situation worse in the shortterm or longer term. Assess the risks (how approaching a woman will be perceived by others; whether the
encounter might cause violence, immigration problems, etc.). Sample questions that may be asked to assess
security:
- Do you have any concerns about carrying out this interview with me?
- Do you think that talking to me could pose any problem for you, for example, with those who live
with you, or for your family, friends or anyone who is assisting you?
- Have you ever spoken with a professional about your feelings, emotions? How was that
experience?
- Do you feel this a good time and place to discuss your experience? If not, is there a better time and
place?
Making the initial contact: simply approaching a woman in a trafficking situation enquiring about, or asking to
speak to a specific woman may put her at risk by raising suspicions about her loyalty or her intentions. Women
are rarely unsupervised. Even those who appear to be alone are commonly being watched. When the woman
is still in the network, the best way to approach her is through the contact with traffickers, even with all
ethical dilemmas and possible obstacles that this may create.
Identifying time and a place for conducting the session: consultations should be conducted in a secure and
completely private setting, and carried out in total privacy; they should not be held in a location where
persons pass by or may drop in or where random interruptions may occur making the woman ill at ease.
Sessions in the presence of children may cause distress and trauma and may result in a womans words being
repeated to others. The woman should be free to reschedule or relocate the session to a time or place that
may be safer or more convenient for her.
Conducting the session: Events can change suddenly during the session. These changes may pose physical or
psychological risks to a woman, and even to the humanitarian workers. The woman can begin to feel unsafe or
ill at ease at any time; then it is important to pick up on these clues, both because the consultation situation
may have become dangerous and because a womans discomfort often means that she is not willing or able to
be forthright. Be attentive to signs such as someone entering the room or walking by, questions that make her
suspicious or nervous of consultants intentions (specific names or addresses...), the professionals loss of
confidence or showing anxiety.
Closing the session: as in all other settings this is a key moment of the treatment. Additionally it very much
probable that a first session will become the only one. Whenever this is likely to be happening, use single
session recommendations in a proper way.
Prepare referral information: be prepared to provide information, if possible in the native womans language
and the local one, about appropriate legal, health, shelter, social support and security services (locally and/or
in the place of reception), and to help with referral, if possible and requested. However, this should be
happening in an ideal situation, but in order to be possible security situation must be very carefully analysed
and coordination members would be making the correspondent decisions.
Referrals contacts and knowledge of the organizations: this task will be mainly in the shoulders of
coordinators; however for the direct professionals working with victims it is important to have solid
knowledge of those organizations to which we could be referring cases. Before any organization is included in
our list, we should make certain that the organizations services are legitimate and appropriate. In locations
where there are no support services, it is necessary to be resourceful and identify organizations that are
sensitive and willing to provide different services to women in need. They may need to be briefed on the
22
Based on: Zimmerman, C. (2003). WHO Ethical and safety recommendations for interviewing trafficked women. Geneva: WHO publications
20
nature of the problem of trafficking and the possible range of assistance that might be required of them. Be
discrete when providing referral information.
Ensuring anonymity and confidentiality: Protect a womans identity and confidentiality throughout the entire
process. Explain confidentiality and the fact that there is no need to give her name and other personal details
is she does not want to. The contents of the confidential encounters should only be discussed with other who
is bound by the same duty of confidentiality and the specific information is relevant for the others role
(medical personnel, supervisors). Be careful where and how the information is shared.
Respecting a womans choices regarding her situation: even women in the most abysmal circumstances may
choose to refuse offers of help (medical or psychological assistance, provision of goods), but that is their
option!
Prevention of re-traumatisation: as in other highly traumatizing situations, asking a woman to talk about
experiences that were frightening, humiliating and painful can cause extreme anxiety. Many women feel
ashamed of what they have done or what has happened to them. A womans distress from a session may
occur during, but may also emerge before or after. For many women it is stressful to anticipate a session
where her experiences will be discussed. Women may also review and regret what they have recounted long
after a session has ended. Anticipate these consequences and adjust the session following these risks.
Group counselling or therapy is not much recommended in principle with victims of trafficking still in the network. It is
difficult to ensure the minimum of confidentiality that should be kept within the group, and too sensitive issues could
be addressed during the activities.
Apart from individual counselling or short therapy whenever possible, other approaches could be of much help. This is
the case of Social and Recreational activities as it was mentioned as a general approach. Taking into consideration that
women have different backgrounds, it logically follows that the women have different needs and interests, thus the
activities organized for them should be varied, adaptable, and consulted with them. These activities have educational,
therapeutic, social and rehabilitation purposes:
- Decrease the level of stress and trauma and promotes relaxation,
- Improve group relations and group cohesion
- Have an educational function due to the practical skills women are learning and enhancing through
activities such as tailoring, knitting, hair dressing, painting, etc.
- Are a productive, structured use of free time
- Identify skills that women can potentially use in a profession in their country of origin or reception
- Expand the womens skills
Dilemmas and concerns regarding the work with victims of Human Trafficking:
Restoring peoples ability to make their own choices seem difficult if not impossible in a trafficking setting in
which people are deprived of their freedom.
Often problems have to do with the fact of trafficking itself, therefore the role of the psychologist or
counsellor to help them adjust and tolerate the conditions becomes paradoxical: ethical dilemma related to
the possible conception of MSF being perceived as supporting the network.
When migrants report incidents of verbal and/or physical violence by traffickers, protection and safety of
patients cannot be ensured and the role of MSF towards these violations is not easy. Sometimes MSF can alert
High turn-over of migrants and short length of stay makes difficult to maintain a trusting relationship between
professionals and victims of trafficking.
Single individual sessions are not always the best option.
Risks of intervening with victims through psychosocial/mental health activities for the access. E.g. chairmen
becoming suspicious with these interventions.
Limits for the positive mid-term impact of the psychosocial care in this context.
21
Pandoras box
Possibility of working in counselling without a first stage of setting problems? (in order to preserve
9. Interventions with Migrants in Destination country/state/community

The immigrants Ulysses Syndrome, briefly mentioned above is characterized on the one hand by the fact that the
individual suffers certain stressors or affliction, and on the other, by the fact that he presents a series of symptoms
from several areas of psychopathology.
Main potential stressors of migrants already in destination (Ulysses Syndrome):
Loneliness and the enforced separation from loved ones.
Sense of despair and failure felt when the migrant, despite having invested enormously in the emigration
(economically, emotionally, etc.) does not even manage to gather together the minimum conditions to make a
go of it.
Need to fight to survive: to feed him, to find a roof to sleep under, etc.
The fear, the afflictions caused by the physical dangers of the journey undertaken (sailing on the patera/
boat, hiding away in trucks) and typical coercive acts associated with journeys that are organized by the
mafia and other groups that extort and threat the immigrants. Fear of detention and deportation.
Symptomatology (Ulysses Syndrome):
> Area of depression: fundamentally sadness and crying
> Area of Anxiety-related disorders: tension, insomnia, recurrent and intrusive thoughts, irritability
> Somatic symptoms: above all migraines (im-migraines), fatigue, osteo-articular complaints
> Symptoms of confusion: tempo-spatial disorientation, depersonalization, derealisation, etc.
> To be added, an interpretation made from the perspective of the subjects own culture.
Coming back to the dilemma regarding clinical labels; if we consider that the common general reaction of the migrant
is normal considering the experienced stressors, creating a new condition (Ulysses Syndrome) is a problem for some
authors. However, as a syndrome it is described as a group of symptoms, not as mental disorder, and additionally it
helps for accessing health care, taking care of not pathologising and avoiding in the same time incorrect diagnosis.
Regarding possible interventions the scenario of immigrants, already in their place of destination leaves many more
possibilities than the previous stages, as in principle there are more chances to do complete individual processes with
follow-up possibilities, and other activities related to health promotion, communitarian interventions, etc., are
supposedly less restrictive and more accessible. Unless other obstacles are found, the basic model of intervention
proposed in general would apply for this context.
Dilemmas and concerns regarding the work with Migrants in destination:
When migrants report incidents of verbal and/or physical violence by authorities, and protection and safety
cannot be ensured for them, the role of MSF towards these violations is not easy. Sometimes MSF can alert
Single individual sessions are not always the best option, when there is not possibility for follow-up.
Difficulties to ensure follow-up of external referrals (e.g. psychiatric cases).
Pandoras box
22

10. Considerations for the work with migrants children

Age is a critical factor in determining appropriate mental health care and support. In cases of traumatic or abusive
situations, children adapt their system of meaning and their behaviour to conform to the world they face. These
children must find a way to preserve a sense of trust in people who are untrustworthy, safety in a situation that is
unsafe, control in a situation that is terrifyingly unpredictable, power in a situation of helplessness. Unable to care for
him or her, s/he must compensate for the failures of adult care and protection with the only means at his or her
23
disposal, an immature system of psychological defences .
Professionals assisting children should treat them being sensitive to the special needs of the child in such difficult
conditions. Whether an adolescent has assumed the role and responsibilities of an adult commonly reflects his/her
own culture. However, regarding paediatric and adolescent health management, cultural and legal definitions of the
country or region concerned must be respected, but only to the extent they do not conflict with the international
agreed norms for administering treatment, obtaining informed consent, medical case management protocols and
similar standards of care.
Caring for migrants children and adolescents requires:
Developing approaches that demonstrate respect and promote participation
An understanding of the complex ways in which their past experience has harmed them
Tailoring services to meet the needs of each age group and in ways appropriate to the age and characteristics
of the child concerned and never merely following programmes designed for adults
Implementing strategies aimed at mitigating the effects of past trauma and fostering healthier patterns of
development.
Participation. International standards state that children should be given the right to express their views freely
on all matters concerning them, and their views should be given due weight in accordance with the age and
maturity of the child (CRC, Article 12). Professionals must provide full information at a level a child can
comprehend to allow the child to participate in decisions affecting her/his well-being; they must listen to
children and take their views and decisions seriously.
Care for children and adolescents must be provided by trained professionals, aware of their special needs, which are
clearly distinguished from those of adults. Professionals trained to deal with child abuse should be selected carefully.
Some principles when meeting children individually:
Find out as much as possible about the childs case prior to the interview (e.g. parents, friends, inmates, police
officers etc.) and make clear and friendly introductions (talking about something the child is familiar with helps
to establish a rapport).
Create a space that is safe and comfortable for conversation (include toys, books, games, etc., to help build a
rapport).
Establish a rapport by talking about, or doing things that are not related to traumatic experiences (e.g., discuss
things the child is familiar with, play games).
Dedicate adequate time for discussions and do not rush.
Use appropriate and child-friendly language (pick up terms the child uses).
Check regularly the level of understanding and comfort
Explain things in a manner the child can easily comprehend (use visual aids wherever possible).
Keep the atmosphere simple and informal (e.g., do not assume an air of interrogation or press for responses).
Begin with open-ended questions, allowing the child to give her/his own account. Avoid leading questions,
e.g., Did the person abuse you? and use more open questions, such as, What did the person do?
Do not pursue and press for details when there are signs that the child has told all s/he knows. However, also
bear in mind that children will leave information out if the right question is not asked, and will give the answer
they believe the consultant wants to hear.
23
Herman, J. L. (1997). Trauma and Recovery. New York: Basic Books
23
Close the consultation in ways that reassures the child that s/he has done well, and that you will be available
whenever s/he needs to talk again.
Learning and education is one of the cornerstones of child development. As soon as possible, it is necessary to begin
fostering learning by offering educational classes, tutorials, or entering children in local school programmes (when safe
and appropriate). Where possible and appropriate, peer counselling and peer education techniques should be
considered.
11. Summary of some Operational Issues

Following the proposed issues to be developed for the mental health area, during the evaluation finalised in October
2010, regarding MSF OCBA Migration projects, mentioned in the beginning of the present document; this paragraph
contains a summary of the current outcomes and proposed operational matters.
Specifically for the issue of interventions in Detention centres, refer to paragraph 7.
How to do mental health with population we see very shortly

Short-term MHPS interventions are recommended as a general practice when working with migrants in order to
encourage supportive responses to negative reactions in brief period of time.
Interventions targeting migrants in transit, in detention or migrants victims of trafficking are subjected to the short
length of stay/detention and as a result the development and maintenance of a trusting relationship between mental
health professionals and migrants is compromised.
Specifically, brief psychotherapy, short-term mental health/psychosocial counselling, psychological first aid and singleshot MH consultations are the most commonly used interventions in migrant mental health care. The single-shot MH
session model is a psychotherapeutic strategy adjusted to those situations where limitations linked to organisational,
24
contextual or individual factors make impossible or improbable to establish a multi-session strategy .
Regarding medical mental health treatment, e.g. provision of psychotropic medication, is not recommended mainly
because adherence to treatment and follow-up visits cannot be always ensured. For acute conditions psychotropic
medication may be prescribed only by medical doctors.
Cultural issues (experience has demonstrated that when conditions are provided safe place,
confidentiality, freedom to talk patients seem to respond, but this would require further research)
Field experience has demonstrated that when conditions are provided, e.g. safe place, confidentiality, and freedom to
talk, migrants seem to respond to treatment practices. Trust-building activities and information sessions are capital
towards the realisation of this goal. However, this is not always the case.
There are scenarios where despite the fact that the minimum safety conditions are provided by MSF and the general
context, migrants do not express themselves as a result of their deteriorated mental health state.
Treatment of serious cases medicines

Mental disorders need to be considered and treated after somatic causes have been identified and excluded by
medical doctors. Equally, patients may have physical symptoms that are rooted in mental illness: dyspnoea and heart
palpitations may be signs of panic attack (acute anxiety attack); anorexia and pain part of a depressive symptom;
delusions of organ dysfunction part of a psychotic disorder.
24
Martinez, C. (2011) Document for guiding decision-making and implementation for MHPS single session, MSF OCBA.
24

25
In emergency psychiatry the DIVINE MD TEST is used for recalling various medical conditions that may present with
mental health manifestations. General medical doctors need to be trained on the basic principles of psychiatric
diagnostics and prescription.
Drug therapy is only one aspect of the treatment of severe mental health disorders. Additional therapeutic measures
such as counselling, family support, psycho-education, supportive psychotherapy and addressing relevant social factors
must be always considered.
The use of certain psychotropic drugs is associated with tolerance and may lead to dependence with withdrawal
symptoms upon cessation. This may be a serious issue of considerations particularly when dealing with migrants,
whose follow-up consultations cannot be assured.
For cases that need specialised psychiatric care, a referral network needs to be established. In case of absence of such
services, MSF can advocate and lobby international and national institutions or consider of integrated psychiatric
interventions in their medical activities.
Referral possibilities
MSF has limited capacity to respond to the global needs of every target migrant population.
A referral network needs to be established in order to respond to:
Social protection and legal issues
Social and practical needs (accommodation, NFI, schooling of children, social integration to host
community/society etc.)
Specialised psychiatric services
of the migrant target population.
How to adapt to lack of local psychologists

There are different options in responding to the lack or absence of national/local psychologists:
a) Fill in the positions by expatriate psychologists working together with cultural mediators, who will be
ultimately trained as lay counsellors;
b) Recruit, select and train skilled lay people as lay counsellors;
c) Train psychiatric nurses in basic principles of counselling, brief psychotherapy and other MHPSS interventions;
Translation issues
There is a need for interpreters who will play the role of cultural mediators, rather than of translators to
accompany and facilitate the work of MHPS staff.
The cultural mediators will be assigned to work closely with national and international MHPS staff and further trained
in principles of communication skills and counseling. As a result, in the long-term there will become lay counselors.
MSF OCBA has compiled a list of practical tools on how to work with interpreters in mental health programs [MSF
OCBA MHPSS DVD, version 1, 2011].
12. Human Resources Issues

Profiles required for a migration project would vary according to strategy, specific needs, coverage of the intervention,
etc. Human resources usually working in MHPSS with migrants include:
Clinical Psychologists
Social Psychologists
Psychiatrists (though commonly they would not be part of the team, but as referral professionals)
Psychiatrist Nurses (not usually required)
Counsellors (already professionals or specifically trained for the job, including peer counsellors)
25
Drogoul, F (2010) Prescribing psychotropic drugs. MSF OCP
25

Interpreters and/or Cultural Mediators

Social Workers
Community (Mental Health) Health Workers
Animators (for social and recreational activities)
Persons receiving care who do not require immediate specialized psychiatric attention (medical treatment,
hospitalization), may benefit from ongoing mental health support from psychologists, psychiatrists, nurses or social
workers trained in mental health. In addition, persons who receive informal or short-term training in mental health or
psychosocial assistance play an important role in providing a therapeutic environment (e.g., including sensitizing other
staff) and offering psychosocial support to migrants.
Lay counsellors (specifically trained to work with communities) have a very important role in psychosocial support.
However, short-term or informal training courses (e.g., three-week training) in mental health or counselling are not
sufficient to enable staff to be the primary diagnostician, or implement psycho-therapies or medical treatment. Job
descriptions must clearly defined responsibilities and tasks.
When offering MHPSS support to migrants, it is advisable that each individual is assigned to a specific MHPSS
professional. Therefore, even if sometimes the migrant will be consulted both by a psychologist and a counsellor, and
even a health practitioner, one of the first two will be in charge of the general MH follow-up of the patient
This should help to ensure that:
the person knows whom to contact for information and requests
the person does not feel lost in a maze of services and procedures (extended projects)
information is not disconnected or lost
personnel do not duplicate tasks
the person does not have to repeatedly share the same information,
the process of developing trust and relationship-building is fostered
In all cases, but more specifically in the case of working with victims of trafficking, adequately select and prepare
interpreters and co-workers. It is important to make certain they have no involvement with any trafficking agents, and
to assess whether they are fully prepared to work on such a sensitive subject. Interpreters and counsellors who speak
the same language may make the respondent feel more at ease, and thus help to build trust. However, it can also have
the opposite effect. Women may not trust, or may feel ashamed speaking in front of someone from their community or
same cultural background. Some women feel more embarrassed to talk about stigmatizing subjects (e.g. sex work,
sexual abuse) that are proscribed in her culture in front of someone from the same culture and instilled with the same
codes. Moreover, less discreet interpreters or counsellors may treat a womans speech as good local gossip. Ask the
woman if she has a trusted friend or colleague who she prefers to assist her or to help in translation to the expatriate
professional (if it is the case).
In some cases, such as meeting women in sex work, male workers may have easier, less conspicuous access. However,
in many cases involving trafficking, women have been betrayed, physically or sexually abused by men (e.g. family
members, agents, employers, military) and may distrust, feel ill at ease, or embarrassed to disclose personal details to a
man. In circumstances where it is impossible to safety contact a woman in prostitution outside her place of work, it can
sometimes be useful for a man to make the initial approach, informing the woman of his purpose for being there and
evaluating the following steps. As in some cases a woman may prefer to speak to a male, believing that another woman
will be more judgemental, more condemning than a man or because the trafficked woman has been abused by a
woman, whenever possible, we should ask if she has a preference.
Consider psychological well-being of the staff!!!
13. Conclusions
Some basic principles and guiding actions have already been successful and recommended in MHPSS with
migrants.
Models of intervention are developed; however specific designs and adjustment of activities and tools should
be always done prior the decision of the opening of a project.
26
With different and adjusted combinations, and following identified needs and installed capacity but MHPSS
with migrants should in principle not only provide individual support, but group activities, community visits
and networking, sensitization and training of other professionals who have access to the same population.
MHPSS component might be ideally integrated in broader health projects.
In some cases, such the work with migrants in DC and with victims of trafficking, minimum requirements have
to be met in order to enable setting up MHPSS activities.
Extreme care and sensitivity has to be dedicated to each activity by professionals. Some basic principles and
ways of doing, already assumed in mental health in other contexts do not apply in some migration scenarios.
We remain with dozens of concerns and dilemmas, some of them partially solved, and other still far to be met.
This paper aims to be part of a dynamic process of sharing and learning, always trying to improve our
interventions with beneficiaries, who always deserve our efforts!
14. Additional Tools

Useful MHPS tools that would be useful in migration settings:
DVD Mental Health & Psychosocial Support Documents & Tools. MSF-OCBA (Version December 2011)
MSF-IWG (2009). Mental Health Counselling Guidance
De Jong, K. et al. (2007). Referral Criteria Mental Health in PHC, MSF working-group
Mental Health HIS version 7; 2012. MSF-OCBA (for medical data collection in projects integrating mental health)
Martnez, C. (2009). Recommendations for assessment & planning of mental health and psychosocial support
interventions in Emergencies. MSF-OCB
Martnez, C. (2009). Guidance for brief mental health assessment by field team. MSF-OCB
Martnez, C (2011). Document for guiding decision-making and implementation for MHPSS Single Session. MSFOCBA
Martnez, C (2011). Mental Health and Psychosocial Support (MHPSS) in emergencies Briefing Paper for guiding
decision-making and interventions. MSF OCBA.
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Thanks to all migrants who have participated in MSF activities, to whom this is of course dedicated!
January, 2012
29

Addressing Mental Health Needs of Migrants - msf-OCBA 2012 - EN

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Frame and Guidance on

Addressing MHPS Needs of Migrants. MSF-OCBA 2012

2. Key concepts and definitions related to Migration

Addressing MHPS Needs of Migrants. MSF-OCBA 2012

Internally Displaced Persons (IDPs):

The Guiding Principles on Internal Displacement, 1998, Introduction, paragraph2.

Addressing MHPS Needs of Migrants. MSF-OCBA 2012

Differences between Human Trafficking and Smuggling:

3. The context of Migration

UNODC, 2006, p. XV, ASI: 2005, p. 6.

MSF OCBA, 2009. Background paper on Migration

Addressing MHPS Needs of Migrants. MSF-OCBA 2012

4. MHPSS consequences of Migration

Stages of Migration and Factors Linked to Psychological Distress10

Age, Gender, Reason,

Economic, social, educational

Support, Alone / Group

Based on Bhugra & Jones, 2001

Addressing MHPS Needs of Migrants. MSF-OCBA 2012

Psychological reactions of migrants

Main difficulties and concerns by migrants :

Moyerman & Forman, 1992

Addressing MHPS Needs of Migrants. MSF-OCBA 2012

Psychiatric diagnoses and labelling

Collazos et al., 2008

Addressing MHPS Needs of Migrants. MSF-OCBA 2012

5. General Approach in MHPSS with Migrant Population

Addressing MHPS Needs of Migrants. MSF-OCBA 2012

Addressing MHPS Needs of Migrants. MSF-OCBA 2012

I. Mental Health Promotion and Psycho-education

Addressing MHPS Needs of Migrants. MSF-OCBA 2012

II. Individual & Group Counselling and Therapy

Addressing MHPS Needs of Migrants. MSF-OCBA 2012

III. Community interventions/IEC

Konrad & Santonja, 2003

Addressing MHPS Needs of Migrants. MSF-OCBA 2012

IV. Social and Recreational Activities

V. Awareness and Training to Health, Social and Education professionals

General considerations related to interventions

Addressing MHPS Needs of Migrants. MSF-OCBA 2012

6. Interventions with Migrants in Transit

Addressing MHPS Needs of Migrants. MSF-OCBA 2012

7. Interventions with Migrants in Detention Centres

Addressing MHPS Needs of Migrants. MSF-OCBA 2012

8. Interventions with Migrants Victims of Trafficking

The impact on detention on migrants health. MSF Briefing Paper , 2010

Addressing MHPS Needs of Migrants. MSF-OCBA 2012

Addressing MHPS Needs of Migrants. MSF-OCBA 2012

Social and psychological

Core components of the

Reduce Fear and anxiety

Restore attachment and

Offer emotional support and

Destruction of values central

Shattering of previously held

Restore meaning and purpose

Humiliation and degradation

Restore dignity and value

Reduce excessive shame and

Supportive Responses to common reactions to trafficking in a service setting

Addressing MHPS Needs of Migrants. MSF-OCBA 2012

How reactions may manifest themselves