The stories Shamaila Khan, PhD, heard when she volunteered at a Rohingya refugee camp in Bangladesh in March still haunt her. One of the first accounts was from a mother who told her how Myanmar soldiers had set her house on fire, with her husband and father-in-law trapped inside. She had fled the house with her infant, but when the soldiers spotted her, they wrested the infant from her arms and tossed the baby into the fire, then raped and beat her.

"The brutality is just unimaginable," says Khan, a psychologist at Boston Medical Center who directs Boston University's Center for Multicultural Mental Health.

Khan, who traveled to Bangladesh as part of an Islamic Medical Association of North America (IMANA) mission, is just one of many psychologists helping Rohingya refugees who have fled Myanmar (formerly known as Burma) in the face of human rights violations and violence. A Muslim minority population in Buddhist majority Myanmar, the Rohingya have long been persecuted. Although the Rohingya trace their heritage in Myanmar back to the eighth century, the government rejects their indigenous status and insists that the people they call "Bengalis" are interlopers from neighboring Bangladesh. As a result, the government denies the Rohingya the right to public services, freedom of movement, even citizenship.

Violence and human rights violations intensified after Rohingya rebels killed nine soldiers in 2016. Since August 2017, 671,000 Rohingya have fled across the border into the Cox's Bazar district of Bangladesh in what the United Nations High Commissioner for Refugees (UNHCR) calls "one of the largest and fastest-growing refugee crises in decades."

Joining 213,000 Rohingya who had fled in prior years, they have created what the UNHCR describes as the world's most densely populated refugee settlement. More than 600,000 Rohingya—more than the population of France's third-largest city, Lyon—now live in one camp called the Kutupalong-Balukhali Expansion Site.

"Some of our Western tools and formulations don't necessarily apply to these situations," says Khan, pointing to depression inventories as one example. "How can you ask the standard questions to assess depression—questions like ‘How are you eating and sleeping?'—when whatever food they're given by UNICEF is all they have to eat and they have nothing to sleep on in makeshift shelters made of bamboo sticks and tarps?"

To help this deeply traumatized population, psychologists are mobilizing lay counselors and providing psychological first aid, which offers emotional support and practical help to those in crisis. They're also conducting research, in Bangladesh and beyond.

A traumatized population

Unfortunately, there's a huge gap between the mental health needs of the Rohingya in Bangladesh and the support available, says Amanda B. Clinton, PhD, senior director of APA's Office of International Affairs, who led a recent APA International Learning Partner Program trip to Bangladesh.

In addition to trauma, says Clinton, the Rohingya in the camps have limited educational opportunities, virtually no chance of working and—as a stateless people—an uncertain long-term future. "They literally have no place to go," she says. "Between the trauma and the hopelessness, the mental health needs are extraordinary."

And while trip participant Minnah W. Farook, a University of Kentucky doctoral student in counseling psychology, was struck by the refugees' resilience, she also acknowledges the barriers that add to the difficulty of getting them the help they need.

Rohingya refugeesFor one, the Rohingya language—while understood in the border area of Bangladesh—isn't understandable by most Bangladeshis, including psychologists coming from the Bangladeshi capital of Dhaka. The Rohingya typically don't know what mental health services are and how they could help. And the comunity around the refugee camps is increasingly frustrated. "There are more Rohingya refugees than the local population," says Farook, who was born in Bangladesh. "Bangladesh is a poor country, and even though they want to help them, they don't have the resources."

To tackle those challenges, the initial focus has been providing psychological first aid, says Santa Rosa, California-based psychologist Cindy Scott, PsyD, who directed mental health activities for Doctors Without Borders in Bangladesh until February. Developed jointly by the National Center for PTSD and the National Child Traumatic Stress Network, psychological first aid offers physical and emotional comfort, information about stress reactions and coping skills, practical assistance and referrals to people in the aftermath of crises, explains Scott, who drew on the "Psychological First Aid: Field Operations Guide" as well as the World Health Organization's "Guide for Field Workers."

Instead of providing services directly, Scott hired, trained and supervised lay counselors from the Bangladeshi community and master's-level clinical psychologists from Dhaka. They assess cases using a newly developed scale that uses pictures of people carrying increasingly heavy loads of sticks or bricks to rate their levels of distress and functioning. "We'd ask, ‘How heavy is this problem that you're describing?'" says Scott. More than 300 Rohingya volunteers go tent by tent identifying urgent cases and educating refugees about mental health care.

Now the needs of these Rohingya refugees are shifting as the immediate crisis has passed. "Psychological first aid is not enough now," says Scott. "As part of the post-trauma reaction, people are quite irritable and volatile." Domestic violence and community conflict are increasing. And women who were raped are now discovering they are pregnant. In response, Doctors Without Borders is training counselors to provide cognitive-behavioral therapy and relaxation methods.

The organization also plans to reach out to the traditional healers the Rohingya often turn to in crises. Many of the refugees suffer from what Western psychologists would diagnose as panic attacks, suddenly feeling like they can't breathe and even fainting. For the Rohingya, says Scott, "this kind of sudden attack can be interpreted to be an evil spirit" that needs intervention by a traditional healer. Unfortunately, she says, these healers often respond by injecting patients with haloperidol and other Western psychotropic medications obtained from pharmacies set up in the camps. "This is, of course, very dangerous," says Scott. "We were getting people with severe side effects from inappropriate dosages of psychotropic medication."

Another source of help is the Bangladeshi government's Multi-Sectoral Programme on Violence Against Women, which is focusing on the estimated 50 percent of women who have faced sexual violence, either in Myanmar or while in the camps.

When lay counselors identify women with symptoms of trauma, depression or other mental health problems, they persuade them to join a group session that teaches breathing exercises, muscle relaxation and other stress-management strategies.

"All the women who are living inside the camp are in grief reaction," says Anita Rani Saha, a clinical psychologist and regional coordinator for the program's Regional Trauma Counseling Centre in the Kutupalong camp. If the counselors see that group participants have severe symptoms, they refer them to Saha and her colleagues for more in-depth assistance.

To boost mental health care capacity, Khan is developing a treatment protocol and adapting the psychological first aid training she provides to IMANA volunteers and others interested in helping the Rohingya.

The training will emphasize the Rohingyas' history and current context, says Khan, explaining that the human rights violations and extreme brutality these refugees have experienced set them apart from other refugee populations. The training will explain how the Rohingya often express psychological distress via bodily pains and suggest effective clinical approaches, including giving them skills such as relaxation and breathing exercises they can use on their own, creating separate spaces for women who have experienced sexual violence and encouraging refugees to share their stories. "Having somebody bear witness to your story is very powerful and healing," says Khan. "It makes them feel that their pain and suffering matter."

Research priorities

Researchers, in Bangladesh and elsewhere, are also working to improve the Rohingyas' plight.

At the University of Dhaka, for example, associate professor and clinical psychology department chair M. Kamruzzaman Mozumder, PhD, is collecting data about the attitudes that Cox's Bazar's Bangladeshi residents have toward the refugees who have settled around them. Nearly 200 interviews have revealed that locals have mixed feelings. While they appreciate the aid-related jobs and development that have accompanied the influx of refugees and the national and international humanitarian forces who are helping them, they also worry about increased crime and increased traffic as truckloads of relief supplies flow into the area. Environmental degradation and the potential for monsoon landslides are another concern now that the hills have been stripped of their trees to make way for the sprawling camps and to meet the refugees' needs for wood to feed their cooking fires.

The interviews reveal very high levels of prejudice, says Mozumder, noting that many view the Rohingya as a "negative culture." Even though Mozumder believes most of the refugees won't receive Bangladeshi citizenship and will be stuck in their current situation for a long time, the locals also worry about the Rohingyas' integration into the community and Bangladesh as a whole. Locals worry that the Rohingya could create a population imbalance in a small, already overpopulated nation, says Mozumder, who hopes to use the data as the basis for interventions combating anti-Rohingya prejudice.

Of course, not all Rohingya refugees are in Bangladesh. Anne Saw, PhD, an assistant professor of clinical/community psychology at DePaul University, is engaged in research with Rohingya refugees in Chicago, some of whom arrived in the United States seven or eight years ago, some in the last few months. (Although it's hard to determine how many Rohingya have resettled in the United States or even in Chicago, says Saw, she believes that Chicago's population of 1,000 to 1,500 Rohingya may make it the largest concentration. Milwaukee, Buffalo, St. Louis and Phoenix also have Rohingya communities.) Saw's goal is to work with the community to figure out what mental health interventions might be most useful.

Although the community is quite resilient, says Saw, anxiety on behalf of friends and family left behind increases along with spikes in violence in Myanmar. Because they are largely illiterate, English as a second language courses and job readiness programs can be extra difficult and anxiety-producing. And the rise in Islamophobia in the United States has also spurred new fears. At the same time, says Saw, "people are kind of resistant to addressing any mental health concerns because there's stigma in the community about naming problems as having a psychological origin or characteristic."

To help the community identify its most pressing needs and palatable services, Saw and her colleagues are working on engagement projects at a community center established in 2016. Support groups, for example, give older Rohingya a place to talk about what's on their minds and share happy stories of growing up in Myanmar. Saw is also pairing young Rohingya mothers with graduate students from psychology and other disciplines who can assist with practical concerns such as learning English, finding jobs or simply finding meaningful ways to spend their time. Because most of the young mothers prefer to stay home with their children rather than find jobs, the women and grad students are brainstorming ways they can overcome the resulting isolation. For some, the solution has been involvement in a community gardening project.

"These are indirect interventions we hope will improve people's mental health and reduce their stress," says Saw.

To join a future APA International Learning Partner Program trip, visit www.apa.org/international/programs/learning-partner/index.aspx.

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Bangladesh Psychological Association

Bangladesh Clinical Psychology Society