Psychosocial services help population of Complexo do Alemão, Rio de Janeiro, deal with daily violence and stress

Milena Osório, psychologist in charge of the programme, talks about the challenges of helping the population improve their quality of life in an environment where fear and stress are dominant

08 September 2008

© MSF

Situated in the western part of Rio de Janeiro, Complexo do Alemão is comprised of  13 deprived communities marked by violence and poor living conditions. Frequent violent episodes leave the population trapped, with little access to health care and living in an environment of fear and stress.

Since October 2007, MSF has been providing psychosocial care to help the population deal with problems triggered by violence, such as anxiety and depression. MSF teams have carried out more than 1,300 consultations with patients of all ages but mostly children and adolescents. Below, the Colombian psychologist Milena Osório, programme coordinator in Brazil who has been with MSF for more than 10 years, talks about the project.

How important are psychosocial services in a project like the one in Complexo do Alemão?

Milena Osório – The mental health aspect is probably what best meets the population’s needs. Of course there are many medical needs, but the psychosocial programme is a private, confidential and neutral space where people can be heard without being judged. It is a place where they can sit down and discuss their problems with psychologists who can help them mobilise their own resources in order to deal with the stress. This is something completely new to this community because people are so used to living in suspicion. They have to be careful of what they say and whom they say it to. Talking to somebody else about a violent event that they have witnessed may be misinterpreted as if they were denouncing something for example. And this could have an impact on their personal safety. Often they don’t want to talk to family members, so as not to worry them. It is very difficult.

In your opinion, what is the most urgent need?

Milena – There is this circle of silence here which the people must keep in order to survive. It is a very oppressive silence. And this had to be broken. It was very important to give the population the opportunity to express what they used to keep inside. There is also the issue with children: most people wanted some support for the children, as they were not doing well at school, they had behaviour problems and were suffering with fear as well as having problems of incontinence.

How does the service work?

Milena – We have a team of two psychologists working five to 15 sessions, though there is some flexibility. It is a brief therapy session, very objective, because MSF did not want to provide a kind of support that would make people dependent. The goal is to help people learn to live better with the problems they have, as they will face the same difficulties over again. It is very different from what you would do in cases when the patient is exposed to one single traumatic event in life. If you’ve had a bad experience, it is very difficult to live in a place that reminds you of that experience on a daily basis. We need to work in a way that will help people find some solution, some alternative.

Do you work with referrals to other health facilities, as it is the case for the medical consultations?

Milena – If we notice that somebody needs a longer follow-up, we refer the patient. If he or she is an adolescent, we refer them to partner organisations providing activities such as capoeira or graffiti. But it depends on the case, as the primary health care system in Brazil is not able to cope with the demand. Unfortunately, in many cases we have nowhere to send patients. So far, we have basically relied on some Medical Health Posts, but they are often fully booked.

Was the psychosocial service already planned from the start of the programme?

Milena – This project was inspired by others run by MSF in contexts of urban violence, such as Haiti and Colombia. Therefore, the mental health component was already planned. However, the type of support we would provide was still an open question. When we did an assessment in 2007, we did some research to find out what the main needs were. This allowed us to shape an appropriate approach.

What was it like to implement this service in a tense environment where people are constantly suspicious?

Milena – When the assessment was done, I got to know the communities and interviewed people in each one of them. We asked if they would like to have that kind of service and we always got positive responses. In the first few months, we had between three and four patients each day. People were testing our services. We have now done more than 1,300 consultations.

What are the main problems found in an environment marked by violence?

Milena – The physical, psychological and social violence that the population in a deprived community faces ranges from an injury in a confrontation to stigmatisation, prejudice and other forms of violence. There is a high level of stress-related problems which can lead to physical problems, such as high blood pressure, panic attacks, breathlessness, palpitations and others. There are also many cases of depression in people who have lost a member of their family. People can’t talk about it, or about how it happened, they can’t get rid of this burden of somebody’s death. With that, the bereavements are very negative. There is a lot of sadness involved in losing a child, in not having a better future, in suffering mistreatment.

How does the project see the role of témoignage?

Ensuring confidentiality about what our patients tell us is key to the project’s success. There has been an increase in the number of patients precisely because they know we are serious about confidentiality. We know témoignage is important and we are thinking of using some data that we have in the future, whilst always keeping the promise of confidentiality that we make to our patients.

You have said that many patients are children. How do you work with them?

Milena – Working with children is not easy, as we also have to work with their parents. A lot of the time the parents are also scared and they don’t know how to deal with the situation or how to help their children. We have to make them aware of how children react to fear, to a noise that they don’t like. This is also one of the most difficult parts of the work.

How does the psychosocial work fit with the medical programme?

Milena – They always go together. If a patient shows some emotional problem when they are being seen in the medical service, they are provided with emergency psychological care. In this case, the doctor calls the psychologists to give some support to these patients. There is also another procedure which is when the medical team refer the patient to the psychologists. When a patient goes through the medical screening, the nurse or health technician often realises that the problem is psychological rather than medical, thus referring the patient to the psychosocial services.