Leninakan, December 1989. It was a year after the earthquake that devastated Armenia that Médecins Sans Frontières launched its first “psy” mission. The author looks back at the reflections and hesitations that surrounded this “time zero of mental health” within the NGO. They will undoubtedly leave their mark on the mental healthcare projects that its various sections will set up in the following decades.
This article is based on ongoing research into the history, practices and debates of mental health within the French section of Médecins Sans Frontières (MSF). The first interviews conducted as part of this project as well as the articles, chapters in joint publications and internal reports consulted, unanimously name Armenia in the aftermath of the December 1988 earthquake as the first intervention in which activities to provide mental healthcare were integrated into a humanitarian aid mission.It should be noted that Médecins du Monde also conducted its first psychological-care mission in Armenia. See Boris Martin, La belle histoire, 1980-2020, Médecins du Monde, Éditions Médecins du … Continue reading There is a great deal of literature about this first mission and many actors still remember, albeit sketchily and hesitantly, its beginnings.
This was very first mental health mission for MSF and is therefore essential reading for anyone who want to study the subsequent developments and debates. I was guided in my approach by two simple questions: how was the original decision to send “psys” into the field made? And what was being done at MSF’s “child psychology” care centre in Leninakan (now Gyumri), near the epicentre of the earthquake, during the eighteenth-month duration of the project between December 1989 and July 1991?
It is interesting to note that the narratives and analyses share common ground, discrepancies and “grey” areas. The point of view from which a person looks at the event obviously influences what they see and retain, and the ensuing discourse: the then president of MSF, the programme manager at headquarters, the child psychiatric consultant, the project coordinator (who is a psychologist) and the anthropologists who studied this project and developed theories about trauma all tell a different story and thus provide a different analysis.
From a methodological point of view, I have tried neither to unify points of view when they diverge nor correct errors by providing a single interpretation or an overview when they become unclear. My own involvement, since I currently work for MSF and have carried out missions for this organisation as a psychologist and coordinator, would make such an approach suspect, even though I did not take part in this first mission to Armenia.
More importantly, it seems to me that to tell the story and recount “how institutions think”Mary Douglas, How Institutions Think, Syracuse University Press, 1986. it is necessary “not to homogenise perspectives but rather to appreciate how we can use diversity as well as possible”.Anna Lowenhaupt Tsing, Friction. An Ethnography of Global Connection, Princeton University Press, 2005 It is not a question of simply respecting what each person says but also of starting a debate on the way in which friction,Anna Lowenhaupt Tsing, Friction. An Ethnography…, op. cit. See in particular Chapter 7: “The Forest of Collaborations”, pp. 391–426. that is to say differences of opinion and disagreements, generate the opportunity for collaboration in pursuit of a common cause.
Examining the grey areas also makes it possible to get a clearer idea of what had to be rejected for reasons of confusion or lack of clarity so that a joint effort could be made. Note, however, that bringing to light these vague areas within the institution and attempting to clarify them has in turn sparked controversy and sometimes heated debateSee the transcript of the 7 July debate in Médecins Sans Frontières’ in-house journal Messages, no. 142, September 2006, Freud in the Field, pp. 1–12. about the organisation’s mental health activities.
“Psy”: the helpful use of a vague term
The accounts of MSF’s first ever mental health programme are by their very nature inconsistent because of the actors’ distance from or, as the case may be, proximity to the field and the various concerns they had and still have. They are consistent and relatively precise, however, until the moment the child psychology project itself begins. This aspect is not clear for most of the stakeholders involved, apart from the psychologists and psychiatrists.
Psychiatric care in the field is sometimes difficult to describe and name for those who are neither psychologists nor psychiatrists, as illustrated by the expression “psy project” which is widely used by the interviewees who are not “psys”. Using the word “psy” to tell the story of these beginnings also avoids having to resort to the notion of “mental health” for some interviewees who reject it. Yet thanks to its vagueness, using the term “psy” (which I myself do in the interviews and in this article) also makes it possible to avoid turning a blind eye to any of the disciplines that constitute the current field of mental health or pitting them against each other. Marc Gastellu, the then head of programmes for Armenia, but also medical director of MSF, points out that one of the debates within the organisation concerned the issue of “psychiatry versus psychology”.Interview with Marc Gastellu, 2 December 2022. Using the term “psy” avoids the need to settle this debate or bring to light a situation in the field that may not be to everyone’s liking – in this case, a MSF project without doctors or treatments.
Taking action: the original U-turn
It was therefore after the earthquake which devastated part of northern Armenia in December 1988 that MSF decided, for the first time, to send psychiatrists and psychologists into the field, where they initially intervened on a one-off basis. It was only a year later, when the medico-surgical activities had ended, that MSF opened a “child-psychology consultation centre” in Leninakan to treat the reactive psychological distress of children and adolescents who were victims of this natural disaster.
Interviews with the then president of MSF, Rony Brauman, director of operations and programme manager for Armenia, suggest that this decision was not the result of internal discussions or reflections that would have gradually led, when the time was right, to the appropriate deployment of mental-health professionals. The various accounts agree that there was a sudden clearing of an institutional impasse.
When Marc Gastellu recalled the pre-Leninakan period, he stated in particular: “Looking back at the context, at the time it was nothing to do with dogma but about something that was said at MSF: ‘We don’t do mental health.’” Recalling her induction into MSF teams, Marie-Rose Moro, a former mental health advisor, said: “The main fear was: ‘Can a psychiatrist join MSF?’”Interview with Marie-Rose Moro, 21 December 2022.
The actors who were present in those early days, however, agree that these reservations were easily dispelled in the post-emergency phase, albeit for a variety of reasons. For some, it came about in response to the problems raised in the field; for others, in response to the institutional need to act. For some, this U-turn in the association’s position is consistent with the teams’ identification of psychological disorders in the surviving population once the other medical problems had gone. “It’s very simple,” said Marc Gastellu Martin, “because she [the head of mission]Marie-Christine Férire, who worked for MSF – Belgium. This first “psy” project was also unusual in that it was an MSF – France project coordinated in the field by a MSF – Belgium team. explained to me that a lot of children were suffering from psychological disorders such as nightmares and bedwetting.”Interview with Marc Gastellu, 2 December 2022.
The director of operations at the time, Brigitte Vasset, admits that she does not remember exactly how the decision was made, even though she visited the field, but she points out how easy it was: “We had 40-60% who ‘hurt all over’… We sent surgeons, but there were far too many. On the other hand, we held appointments… With regard to these 40-60% who ‘hurt all over’, someone said it’s psy-related, and it was pretty easy to open a psy centre. At that time, we held operations meetings, and that’s how we decided.”Interview with Brigitte Vasset, 14 November 2022.
Nevertheless, this new project had to be presented to MSF president Rony Brauman. According to Brauman, it was Dominique Martin (programmes manager, himself a psychiatrist, but not working as such at MSF), who took it upon himself to persuade him to “go down the psy route”,Interview with Rony Brauman, 25 October 2022. suggesting that his wife, Marie-Rose Moro, go on an exploratory mission as a child psychiatrist. At the time, the operations in Armenia were attracting a great deal of attention from the MSF’s president because of the outpouring of solidarity and emotion and the extraordinary amount of donations generated by the earthquake in a country with which France had strong ties. In the words of the former president, this was therefore a “particularly appealing situation from the aid point of view”,Interview with Rony Brauman, 25 October 2022. but MSF was struggling to translate this outpouring into a medical operation.
The Armenian people’s request for aid, and the newly identified opportunity to respond to it by “sending psys”, offered a solution to the institutional problem that MSF then faced, whilst also providing the opportunity to deliver a tangible service to a population whose psychological distress was impossible to deny.See in particular the testimony of Martin Pachayan, in Arménie décembre 1988, https://www.dailymotion.com/video/xemyum
In the end, stressed Rony Brauman, “it was very difficult to leave behind a mass of ruins, both material and psychological, given the very strong emotional bonds that had been fostered there”.Interview with Rony Brauman, 25 October 2022. The all too real social pressure exerted on the organisation to “do something”Rony Brauman, “Natural Disasters: Do Something!”, in Claire Magone, Michaël Neuman and Fabrice Weissman (ed.), Humanitarian Negotiations Revealed: The MSF Experience, Hurst, 2011. combined with the emotional investment of its members, not to mention their clinical and operational resourcefulness, allows us to forget that until then, MSF “did not do psy”.
Inventing a system: the child psychology consultation centre in Leninakan
What did MSF’s first psy project actually involve? The report written by Armelle Seiler – a psychologist and coordinator of the project in the months preceding its closure – is rich in insights. Firstly, Seiler dates the decision to open the centre to September 1989. She points out the insistence of the field teams, particularly that of an expatriate psychologist on her return from the mission who had spent the summer of 1989 working in MSF medical facilities, sometimes in tents, in Yerevan and Leninakan in partnership with Armenian psychologists.Armelle Seiler, Étude de la mission pédopsychologique, Arménie 1989-1991, Médecins Sans Frontières, Épicentre, juin 1992, p. 23. In contrast to the ease with which decisions were made, as suggested by the stakeholders at headquarters, Armelle Seiler wrote: “A lot of time passed between receiving the first alerts from the field and setting up the psychology centre. It seems that MSF did not know how to deal with the psychological consequences of the earthquake.”Idem. She went on to say, hinting at the organisation’s reluctance to implement any psy actions: “It is therefore possible that, on the one hand, the lack of know-how about this type of mission and, on the other, the relative degree of interest at headquarters prevented the search for a more appropriate and faster response.”
The report describes the composition of the team: educators, psychologists, receptionists, maintenance technicians, logistics officers and interpreters, but nowhere is there any mention of doctors or nurses. The report clearly states “that the overall objective of the mission is to provide psychological support to the children of Leninakan who have earthquake-related reactive disorders (no medication or psychiatric treatment should be prescribed)”.Ibid., p. 5.
The reactive nature of the symptoms was very important for MSF. Armelle Seiler stresses that during their visits, the programme manager and the technical advisor remembered the need to stay focused on the victims of the earthquake and not treat chronic pathologies. Yet there were many different types of care and support activities: “activity and expression” groups for children and adolescents led by educators; mother-child therapeutic groups; relaxation sessions; individual psychotherapeutic consultations, and family consultations led by psychologists. By turning this project into a “technical assistance” mission (to use the terminology of the time), the number of training sessions increased in parallel with the medical appointments, at the request of the Armenian psychologists and educators. July 1991 was thus entirely devoted to training, before the centre was taken over by the Armenian team under the dual supervision of the ministries of health and education. Other sessions were organised and supported by MSF in 1992, one of which was co-facilitated by Marie-Rose Moro and Tobie Nathan, at the request of the psychologists and educators who were still working there.
The clinical approach on which this first psychological care centre was based was clearly guided by psychoanalysis. Marie-Rose Moro went to Armenia armed with “these authors and these ways of thinking”,Interview with Marie-Rose Moro, 21 December 2022. namely Therapeutic Consultation in Child PsychiatryDonald Wood Winnicott, Therapeutic Consultation in Child Psychiatry, Hogarth Press, 1971. by Donald Woods Winnicott; works by Selma H. Fraiberg, who worked on the mental health of babies; and works by Anna Freud, who is considered to be one of the pioneers of child psychoanalysis. Moro, a child psychologist, recalls that even though these authors were part of the psychoanalytic movement, they had “worked during the Second World War” and had thought about “the effects that adverse events and conditions have on children”.Interview with Marie-Rose Moro, 21 December 2022. After reading “all Winnicott” as a matter of urgency, she said that she had packed the English and Russian translations of some of these works in her suitcase. And, on her advice, every psychologist going out into the field also took them – just as they would take “guidelines” with them today.
On a technical level, the Leninakan centre therefore seems to have adopted a psychoanalytically oriented psychological and psychosocial approach adapted for use in the context of a humanitarian post-emergency intervention. It thus perhaps heralded at least as much the rise of humanitarian psychiatry (as Dominique MartinDominique Martin, « Psychiatrie et catastrophes : le point de vue d’un humanitaire », in Marie-Rose Moro et Serge Lebovici, Psychiatrie humanitaire en ex-Yougoslavie et en Arménie : face au … Continue reading and, later, Didier Fassin and Richard RechtmanSee the chapter “Humanitarian psychiatry”, in Didier Fassin and Richard Rechtman, The Empire of Trauma. An Inquiry into the Condition of Victimhood, Princeton University Press, 2009, … Continue reading assert) as what has been called, since the 2000s, “mental health and psychosocial support” (MHPSS) in humanitarian practices, i.e. a field with multiple reference points and disciplines.
This first mission is generally considered to have been a success. It provided an answer to the thorny institutional question of “how can we stay?” and paved the way for the mental healthcare projects of the following decade in Romania, Palestine, Guatemala and the Balkans. “A model mission, yes, but will ‘psy missions’ not also become ‘cover missions’ when we don’t know what to do?” asks Marc Gastellu however.Interview with Marc Gastellu, 2 December 2022. Psy projects will always come under suspicion, as if the different motivations and interests that had presided over this innovation were a form of adulteration or deception.
My research will pursue the avenues opened up by the feedback on this first mission to integrate MHPSS activities. My aim is to understand how the common ground and discrepancies and not least the vague and grey areas within the institution have made it difficult for “psy” to become an integral and permanent part of the actions of the French section of MSF.
Translated from the French by Derek Scoins