Mental health and psychosocial needs and response in conflict-affected areas of north-east Nigeria

The conflict between Boko Haram and Nigerian security forces in the north-east of the country has entered its eighth year, with no sign of a long-term resolution. Since the start of the conflict in 2009, more than 20,000 people have been killed. As many as 2,000 women and girls have been abducted and subjected to physical and psychological abuse, forced marriage and sexual violence, forced labour (including performing household tasks), forced to participate in armed operations and repeatedly raped. International Alert and UNICEF, Bad Blood: Perceptions of Children Born of Conflict-related Sexual Violence and Women and Girls Associated with Boko Haram in Northeast Nigeria, International Alert/UNICEF Nigeria, February 2016; Human Rights Watch, ‘Those Terrible Weeks in Their Camp’: Boko Haram Violence against Women and Girls in Northeast Nigeria, Human Rights Watch, October 2014, www.hrw.org. Young men and boys have been forcibly recruited into armed groups, and their families either killed or left not knowing if their wives, daughters and sons are still alive.

The Nigerian security forces have also perpetrated abuses against civilians in the north-east. A report by Amnesty International in 2015 states that more than 1,200 people have been executed, and at least 2,000 – mostly young men and boys – arbitrarily arrested. Civilians from areas under the control of Boko Haram have been tortured. Hundreds of Nigerians have disappeared and at least 7,000 have died in military detention from starvation, overcrowding and lack of medical care. Amnesty International, Stars on Their Shoulders. Blood on Their Hands. War Crimes Committed by the Nigerian Military, Amnesty International, June 2015.

This complex context of protracted violence, abuse, killings, disappearances, enslavement and imprisonment has had a profound impact on the mental health and psychosocial wellbeing of people in the north-east. Millions of people have been affected, either first-hand or through indirect exposure to violence. Entire families and communities live in fear, fleeing their villages to seek refuge in safer areas, bigger cities or neighbouring countries. Report of the UN Special Rapporteur on the Human Rights of IDPs, April 2017. According to the Displacement Tracking Matrix produced by the International Organization for Migration (IOM), by March 2017 more than 1.8 million people had been displaced across the six most affected regions: Adamawa, Bauchi, Borno, Gombe, Taraba and Yobe. A third are in official IDP camps and camp-like settings, with the rest living in host communities, with friends and relatives or in rented or free accommodation temporarily provided by private citizens, churches and other local groups. The scattering of the displaced population across large areas has made locating them and providing them with humanitarian assistance especially challenging. Displacement Tracking Matrix (round 14), ‘Location Assessment Report’, IOM, 31 March 2017.

Psychological distress as a result of violence

Victims of violence report suffering from psychological distress, sometimes severe. Many complain of deep fear, sleeplessness and/or nightmares, generalised anxiety and unexplained somatic symptoms, such as body pain, stomachache and headache. Women and girls who have managed to escape Boko Haram are often marginalised and stigmatised by their communities, who fear that former abductees have been radicalised. The lack of trust these women and girls feel leads them to isolate themselves from their social networks. Some are rejected and abandoned by their families and communities. Children and teenage boys forcibly enrolled in armed groups are similarly affected.

At a theoretical level, the type and severity of a person’s reaction after a life-threatening event depends on a number of different factors: the nature and severity of the event they experience, age, previous exposure to distressing events, personal vulnerability, personal and family history of mental health disorders, coping mechanisms, resilience, physical health, cultural background and the presence or absence of a supportive environment. Most people will experience some symptoms after a highly distressing event, which may last for days or a few weeks. In most cases, symptoms will slowly decrease over time, without the need for any specific intervention.

If the severity of the symptoms is not recognised by the person affected or their family and not treated in time, psychological disorders might develop, such as chronic anxiety, depression, mood disorder, post-traumatic stress disorder, psychosis and, in the case of children, development disorder. Diagnostic and Statistical Manual of Mental Disorders (DSM-5), American Psychiatric Association, 2013. Accurately identifying the psychological needs of victims, and putting in place the appropriate supportive intervention and/or therapy, requires mental health professionals (psychiatrists and psychologists), counsellors, social workers and community workers with the specialist skills, knowledge and experience relevant to supporting victims of violence and people affected by conflict.

International organisations working in Nigeria commonly acknowledge that the mental health and psychosocial needs of conflict-affected people are not met due to the instability of the situation, limited resources, lack of support from authorities and family and community separation. Limited access to health, social and educational services, especially but not only for displaced people, worsen an already critical situation. In Nigeria, where the mental health care system is neglected Mental Health System in Nigeria, World Health Organization, 2006; Oluwakemi Olanike Aderibigbe, ‘A Review of Mental Health and Psychosocial Needs and Responses during Emergencies in Nigeria’, September 2014. and mental health problems are still negatively perceived and seldom discussed, especially in the more conservative areas of the country, people affected by conflict-related violence are unlikely to find proper care. The main risks are that the suffering of the affected person is initially underestimated by mental health staff, the affected individual themselves and their friends and family, and help is sought only when their symptoms worsen to the point where family and community members fear they are ‘crazy’, or they are wrongly diagnosed and incorrectly treated. Although in Nigeria there is no available data on the quality and efficacy of mental health services, it is reasonable to assume that the limited number of psychiatrists, psychologists, counsellors, social workers and community workers in the country are not trained or prepared to deal with the increased needs the crisis is generating.

Mental health and psychosocial needs in north-east Nigeria

Psychosocial support for victims of violence, displaced people and host communities only became an area of focus in Nigeria after Boko Haram’s abduction of more than 200 schoolgirls from Chibok in April 2014 attracted international attention to the crisis. In 2015, IOM conducted a mental health and psychosocial needs assessment in IDP camps in Yola. The assessment highlighted a number of factors causing psychological and psychosocial distress. The majority of people who took part in the assessment reported feeling sad and experiencing negative emotions in relation to their displacement and protracted and widespread violence. Uncertainty over the future, associated with the desire to return home, is one of the strongest factors triggering negative feelings and emotions. L. Giardinelli et al., An Assessment of Psychosocial Needs and Resources in Yola IDP Camps: North East Nigeria, IOM, 2015. In addition, everyone experiences some kind of loss in displacement: loss of property, including the loss of a home, loss of relatives and friends through death or separation, and loss of identity and status. G. Schininà et al., ‘Mainstreaming Mental Health and Psychosocial Support in Camp Coordination and Camp Management: The Experience of the International Organization for Migration in the North-east of Nigeria and South Sudan’, Intervention Journal, 14, November. The last two are particularly relevant for men, especially men living in displacement camps, who, in losing their role as head of the family in a patriarchal society, often suffer prolonged frustration, anxiety and behaviour change, which can result in an increase in domestic violence, among other problems.

The situation is exacerbated by harsh living conditions in overcrowded displacement camps, where food and basic household items are in short supply and services are sometimes delivered in undignified or culturally inappropriate ways. People in camps in north-east Nigeria report high levels of distress due to family separation, where women, small children and teenage girls are accommodated in one wing of the camp and men and teenage boys in another. This is justified as a protection measure, but in fact women and girls are more exposed to violence and abuse due to the lack of family protection, increasing their fear and frustration. Ibid.  People are typically not free to enter or leave the camps, which not only takes away decision-making power and makes people feel imprisoned, but also reduces the chances of finding work, especially for men, exacerbating feelings of despair and increasing dependence on external aid. Giardinelli et al., An Assessment of Psychosocial Needs and Resources in Yola IDP Camps.

Mental health and psychosocial report

Psychosocial support became one of the priority protection responses in north-east Nigeria in 2015. Nigeria: Humanitarian Response Plan, 2016, https://www.humanitarianresponse.info/en/operations/nigeria/document/nigeriahumanitarian-response-plan-2016. IOM was among the first to start implementing a community-based mental health and psychosocial support programme, using mobile teams to reach people in need in different locations. Médecins Sans Frontières (MSF) set up a clinic in Borno State, providing, among other primary care services, psychological support to IDPs, victims of violence and people from host communities through individual, group and family counselling sessions. Save the Children and the UN Children’s Fund (UNICEF) implemented a programme for children and their families through the creation of Child Friendly Spaces and clinics in several IDP camps in Borno State, and the UN Population Fund (UNFPA) provided medical services for women, including psychosocial support. ICRC also established a mental health programme. Slowly, more organisations followed. However, when I left Nigeria in March 2016, the coordination structure (the Mental Health and Psychosocial (MHPSS) Working Group, a subset of the Protection Cluster), lacked a strong lead, and most psychosocial support programmes were implemented in IDP camps, resulting in some cases in similar programmes being offered to the same beneficiaries, with no provision for affected people residing in host communities.

Mental health and psychosocial support is a relatively new domain in the Nigerian emergency setting, and there is a lack of specialised human resources, including in the north-east. There is high demand among mental health professionals in the country for training on mental health interventions in emergency settings and conflict-affected areas, while healthcare staff, social workers and community workers would greatly benefit from training in basic psychosocial support.

Strengthening the MHPSS coordination system at national level, to provide guidance and orientation and act as a reference point for organisations providing mental health and psychosocial support services to conflict-affected people, would address and improve the issues discussed here, and enhance the sustainability of psychosocial support services in the country. The first step would be establishing a dedicated MHPSS Working Group coordinator, along with the creation of guidelines to clarify how to plan a mental health and psychosocial support programme, including the interventions and activities to be included; how to select team members and the backgrounds required; and the training psychosocial support staff need before being deployed.12 The MHPSS Working Group coordinator could also represent the members of the Working Group in other Clusters (Protection and Health, to mention two) and provide technical support and guidance when required.

The emergency context in north-east Nigeria is constantly evolving. With the security forces regaining territory previously under Boko Haram control, displaced people are slowly starting to return to their homes, and the MHPSS component of the humanitarian response will face new challenges as conflict-affected people enter on the long-term process of reconciliation and healing. Sustained support for community mediation and peace-building should be an area of focus in the New Way of Working strategy being developed by UNDP and the World Bank. Particular attention will have to be paid to children born out of sexual violence, who are likely to experience rejection and abandonment by families and communities. Alternative care programmes will be needed for these and other conflict-affected children who, otherwise, will live lives of isolation and abuse, feeding the cycle of violence and compromising healing in north-eastern Nigeria.

Luana Giardinelli is a clinical psychologist and an expert in mental health and psychosocial support programmes in emergency settings. She has worked in Africa, Eastern Europe, Central and South Asia, managing and implementing programmes in mental health and psychosocial support for natural disaster- and conflict-affected people and victims of violence and torture.