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Table of Contents
FIELD REPORT
Year : 2021  |  Volume : 19  |  Issue : 2  |  Page : 233-241

Programming to Address Suicidal Behaviour among Unaccompanied Refugee Minors in a Camp Setting: A Field Report from Ethiopia


1 Psychotherapist-Trainer, The Center for Victims of Torture, Mai Tsebri, Ethiopia
2 Clinical Programs Director, The Center for Victims of Torture, Addis Ababa, Ethiopia
3 Monitoring and Evaluation Officer, The Center for Victims of Torture, Shire, Ethiopia
4 Clinical Advisor, The Center for Victims of Torture, St. Paul, MN, USA

Date of Submission01-Dec-2020
Date of Decision07-Jun-2021
Date of Acceptance06-Jul-2021
Date of Web Publication09-Sep-2021

Correspondence Address:
MA Liyam Eloul
Clinical Advisor, 2356 University Avenue West, Suite 430, St. Paul, MN 55114
USA
MA Medhanye Alem
Psychotherapist-Trainer, The Center for Victims of Torture
Ethiopia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/INTV.INTV_52_20

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  Abstract 


In response to a perceived increase in suicidal ideation and behaviour among minors and especially unaccompanied and separated children (UASC) in camps for Eritrean refugees in Ethiopia, we developed a multilayered response programme. This programme included public awareness and stigma-reduction campaigns, psychoeducation aimed at both UASC and their caregivers, capacity building for humanitarian and community partners, group and individual counselling for UASC and crisis response and postvention. We offer learnings from the development and implementation of this programme, highlighting the importance of working with relevant constructs such as grief, guilt, attachment and identity. It is our hope that our learnings will be informative and helpful to practitioners working with displaced UASC in other contexts. Recognising the heightened risk factors experienced by young people with trauma histories currently in camp settings, we recommend the coordinated development of a suicide prevention and response plan as a core component of any humanitarian response.

Keywords: camp setting, Eritrean, Ethiopia, humanitarian emergencies, refugees, suicide, unaccompanied and separated children, unaccompanied minors


How to cite this article:
Alem M, Githaiga S, Kiflom E, Eloul L. Programming to Address Suicidal Behaviour among Unaccompanied Refugee Minors in a Camp Setting: A Field Report from Ethiopia. Intervention 2021;19:233-41

How to cite this URL:
Alem M, Githaiga S, Kiflom E, Eloul L. Programming to Address Suicidal Behaviour among Unaccompanied Refugee Minors in a Camp Setting: A Field Report from Ethiopia. Intervention [serial online] 2021 [cited 2021 Sep 21];19:233-41. Available from: https://www.interventionjournal.org/text.asp?2021/19/2/233/325807




  Introduction Top


In 2018, Médecins Sans Frontières (MSF) raised the alarm regarding increased rates of child suicide in Moria refugee camp in Greece (MSF, 2018). Nearly 25% of children as young as 10 years old were displaying self-harm, suicidal ideation and suicide attempts. MSF cited the children’s previous exposure to violence and trauma, as well as the ongoing stress, unsanitary conditions and lack of safety in the camps as the primary drivers of this behaviour (MSF, 2018; Nye, 2018). While this is unfortunately unsurprising given previous findings of elevated rates of suicidal ideation and behaviour among refugee youth held in detention (Dudley et al., 2012; Evans et al., 2018; Fekete, 2007), the report raised debate in the mental health and psychosocial support (MHPSS) field regarding the assumed lower risk of suicidal behaviour among children, compared to teenagers or adults (Shaffer & Fisher, 1981). These reports struck a chord for the staff of The Center for Victims of Torture (CVT): since 2016, our team had been striving to respond to increased rates of suicidal behaviour among minors, particularly unaccompanied and separated children (UASC) in the Mai Ayni and Adi Harush refugee camps in northern Ethiopia, where we provide MHPSS services to Eritrean refugees. In this field report, we share our learnings in developing and implementing our suicide prevention and response programme for UASC in a camp setting.


  Background Top


As of October 2020, there were an estimated 139,281 Eritrean refugees in Ethiopia, most clustered in the four refugee camps in the northern province of Tigray (UNHCR, 2020). Approximately 44% of these refugees are minors, of whom 27% are unaccompanied (UNHCR, 2020). This is approximately 16,546 UASC, a figure that is likely an underestimate due to numbers of children that arrive accompanied, but are later abandoned by or separated from their caretakers, due to secondary migration, illness or death.

The enforced military service in Eritrea, resulting in an indeterminate period of indentured servitude to the government, is the primary reason cited by UASC for their migration (Amnesty International, 2015; Belloni, 2020; UNHCR, 2020; van Reisen, 2016). Military service officially begins at age 18, but it is reported that the military commonly forcibly recruits younger children using the practice of “giffa”, or rounding up groups of children for enlistment (Commission of Inquiry on Human Rights in Eritrea, 2016). Both boys and girls are forced into military service, and reports of sexual abuse and assault of recruits are common (van Reisen, 2016). The UN Special Rapporteur on Human Rights in Eritrea determined the national service to be rife with systematic and pervasive violations of human rights and classified these practices as a crime against humanity (OHCHR, 2016). This compounds the prevalent human rights violations faced by civilians, including arbitrary arrest and detention, restrictions on freedom of expression, movement and religion (Amnesty International, 2015; Human Rights Watch, 2020).

The above factors, as well as lack of resources and desire for reunification with family members who have already escaped, draw children as young as 7 years old to cross the border into northern Ethiopia (Hirt & Mohammad, 2013; van Reisen, 2016). While this trend began in the early 2000s, the numbers rose significantly after the regional drought in 2007, peaking in 2015 (African Monitors, 2016). Until it was opened in late 2018, the border between Ethiopia and Eritrea included a “shoot-to-kill” zone patrolled by the Eritrean military (van Reisen, 2016). Many of CVT’s UASC clients witnessed the capture, injury or death of others in their group during their crossing and frequently report experiencing intense fear of capture or death during their journey, as well as exposure to hardship and injury. It has been widely acknowledged by UASC that capture means detention and likely torture, as desertion of the country and of military service is considered treason (van Reisen, 2016). Being exposed to traumatic experiences before and during migration has been indicated to make adolescents and children more susceptible to mental health problems such as anxiety, depression and posttraumatic stress disorder (George, 2012; Steel et al., 2004). Further, the stressors resulting from being unaccompanied by an adult attachment figure have been related to a higher severity of symptoms (Bean et al., 2007).

These symptoms are exacerbated by the fact that escaping military service can put the UASC’s family at risk. Many do not tell their parents they are migrating because “the less they know, the less it can hurt them” (Belloni, 2020). Family members are frequently jailed following the disappearance of a military-aged male (Belloni, 2020). Minors justify to themselves that they will be able to get work and support their families, including sending money to bribe for the release of jailed family members. The realisation that they are confined to camps and unable to work brings feelings of guilt and shame for abandoning their families and putting them at risk. Until the Ethiopia–Eritrea peace agreement in September 2018, most refugees were unable to contact family in Eritrea without putting them in danger. The only updates they could receive were by word of mouth from other refugees who came from their town after them. They were usually unable to send messages home to reassure family members of their safety, creating another source of grief and guilt for UASC. This disruption of families, and particularly the sudden and permanent separation from vital attachment relationships necessary for a child to thrive (Greenberg et al., 1983; Sroufe, 2005) have a severe impact on UASC (UNHCR, 1994). While some of the UASC we have worked with had been informed of the migration process illicitly, most made the decision to cross the border impulsively and based on minimal, often inaccurate, information. Thus, they experienced shock at the conditions during and after migration.

Upon arrival in Ethiopia, UASC are housed at a reception centre while adequate housing is found in one of the camps. When CVT began its minor-centred programming in 2016, the staff at the reception centre reported children experiencing severe symptoms of mental health problems, including night terrors, nightmares, frequent crying, anxiety, bedwetting, anger outbursts, self-isolation and self-harm. Often, the reception centre was overcrowded and there were limited resources and supportive services available. Staff had basic psychosocial training, and overnight housemothers had no psychosocial training. While adults were usually moved to the camps within 3 days, UASC could spend up to 3 months in the reception centre due to shortages of available space in group homes1 and challenges identifying kinship2 or foster3 placements. Once space is found, the UASC is referred to the child protection partner in the camp and is placed in the group or foster home under supervision of a paraprofessional community social worker. At the time, foster parents and social workers had no psychosocial training or exposure, and limited awareness of how to work with vulnerable children. Social workers often had high caseloads and, as community members themselves, experienced significant personal stressors, which resulted in the frequent use of physical punishment.

Similar to what has been found in Moria, the conditions in the refugee camp can exacerbate symptoms: The poor living conditions, inadequate nutrition, threats to safety and significant delays in the resettlement process lead to feelings of hopelessness (George, 2012). Further, UASC refugees can be at higher risk of emotional, physical and sexual abuse due to the vulnerability of their unaccompanied status (Bean et al., 2007). Lengthy stays in the camp seem to increase the likelihood of suicidal behaviour (Van de Wiel et al., 2021). A study of Eritrean UASC refugees referred for resettlement in the United States found that a significant proportion arrived with “substantial mental health needs”, greater than in other groups of resettled UASC, including “significant unresolved trauma” (Sochal et al., 2016). These trends, as with subsequent self-harm behaviours, are similar to those reported among unaccompanied minor asylum seekers in Europe (Gentleman, 2018; Sourander, 1998) as well as the refugee children residing in Moria camp (Nye, 2018).


  Suicide and Self-harm Among UASC Refugees in Ethiopia Top


CVT is an international NGO which has been the primary MHPSS service provider in the Mai Ayni and Adi Harush refugee camps in Tigray, Ethiopia since 2012. With a staff of professional Ethiopian counsellors and paraprofessional Eritrean psychosocial counsellors, CVT provides trauma-informed individual and group counselling, as well as psychoeducation and stigma reduction activities in the community, and MHPSS training to community and partner organisations. Staff are provided weekly live, individual or group supervision by on-site psychotherapists, who receive remote supervision and programmatic guidance from a clinical psychologist at headquarters.

In 2015, CVT began to see an escalation of periodic clustered suicidal behaviour among UASC in the camps. The child protection lead reported 17 suicide attempts that year (10 girls), up from 2 in 2014 (1 girl; Norwegian Refugee Council, 2015). There appeared to be cycles in which a suicide attempt would trigger contagion among other UASC (Hayden, 2015). As a result of the lethal means accessible to UASC (hanging, self-immolation or poisoning with bleach, rat poison or an overdose of common medications), and shared housing, what starts as a private act often becomes a public one, witnessed by neighbours or housemates. Witnessing acts of self-harm has been shown to increase likelihood for contagion, particularly in youth (Gould & Lake, 2013). A variety of immediate triggers were noted: These include lack of contact with family, guilt related to lack of ability to either work to support their family or to complete secondary migration, news of a migrant boat sinking in the Mediterranean, stigma experienced due to trauma responses (e.g. regressive behaviours, night terrors or bedwetting) and bullying based on ethnicity or perceived “evil eye”.

This trend has continued. From 2017 to 2019, 128 children or adolescents reported suicidal thoughts within the previous 2-week period to CVT at intake. This was about 12% of CVT’s minor clients during this period. Nearly three-quarters (72%) of these clients were separated from their family members at the time of the assessment. Of these, 40% reported that they had made plans in the past month to end their life and 33% reported that they had previously attempted to end their life. These clients were as young as 8 years old, with a mean age of 14.4. It should be noted that many UASC do not report suicidal ideation at intake, instead waiting until trust is built before they report the thoughts to their counsellor. Despite this, reported suicidal ideation rates at intake among CVT UASC clients are consistently above 10% (see [Figure 1]). Following intensive sensitisation in 2017, most UASC are now referred to CVT by community members or partner organisations because they are either self-isolating or are becoming aggressive towards caretakers or other children.
Figure 1 Rates of Minor Suicidal Ideation at Intake Assessment

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Suicide in both Eritrean and Ethiopian cultures is highly stigmatised and is perceived as an act against God’s will by many in the refugee community. Whether Coptic Christian, Catholic, Protestant or Muslim (the primary religions of the population), spiritual leaders often preach that one who has died from suicide will go to hell. Even reporting hopelessness or the wish to die is perceived as questioning the will of God. This hinders individuals from discussing their intent openly and receiving professional or social support. People who have survived a suicide attempt are often blamed for their act and ostracized. This elicits feelings of shame and exacerbates their struggles, impeding recovery.

In 2015, prior to CVT’s programming, the common reaction to a suicide attempt was for the community police to be called. These are community members appointed by the Refugee Central Committee of the camp, with no training in crisis response and their intervention was typically to chastise or even beat the child. If severe harm had been caused by the attempt, the UASC would be sent for medical treatment. If not, no consistent follow-up was provided. Often there were rumours or stigma around the youth who made the attempt. The foster family or social worker responsible for the group home was expected “to keep an eye on” the UASC, but were untrained in MHPSS and unprepared to provide support. Following a suicide in a group home or neighbourhood, cases of suicide contagion among others in the group home or the local area emerged, with typically between one and five additional attempts in the following weeks. Minimal MHPSS services are available beyond what CVT offers and there was no coordinated response from medical, protection and MHPSS actors for suicidal behaviour.


  Programme Design for Prevention, Intervention and Postvention4 of Suicidal Incidents Top


CVT developed a multipronged approach to address these needs, which focuses on (a) community awareness raising and stigma reduction; (b) capacity building for community leaders, refugee social workers and staff of humanitarian agencies, including teachers and reception centre staff; (c) psychoeducation for minors and their caregivers5; (d) group and individual counselling for minors identified as being at risk and (e) crisis intervention and coordinated postvention strategies to address attempts and reduce the risk of contagion. To allow for intensive capacity building among CVT staff, selected counsellors with prior experience working with children were allocated to a “minors team” dedicated to developing and piloting CVT’s interventions in each camp in 2016. This team received weekly training on trauma-informed developmental psychology and clinical models, daily live supervision, as well as weekly supervision by a psychotherapist with expertise in working with children and young adults. After the minor-focused programming was fully established, in 2017 the “minors team” was reintegrated into the staff body, and the specialised trainings were disseminated for all staff and incentive workers.

Community Awareness Raising and Stigma Reduction

Due to the heavy stigma around suicidal behaviour, CVT put significant effort into community awareness raising programmes. These were largely carried out through “coffee corner discussions”, engaging and educating gatekeepers, particularly religious leaders, elders, paraprofessional caregivers from partner agencies, teachers and community law enforcement. During these discussions, CVT staff present on MHPSS-related topics, including normalising suicidal ideation as a response to previous experiences as well as the hopelessness and harsh conditions of the camp, contributing factors and protective factors, and identification of early warning signs. Gatekeepers are then engaged in providing feedback and brainstorming effective responses that they or their community could take. Recognising that often a blaming or judgemental response to suicide is rooted in anxiety and not knowing how to respond to suicidal ideation or behaviour, these coffee corner discussions focus on helping community leaders to better understand and more effectively respond to children at risk. They also raise awareness of available CVT services and build closer ties between the gatekeepers and CVT so that the CVT team is alerted when at-risk behaviour is identified. Early referral and therefore intervention have increased the ability of the team to address the needs of at-risk UASC at a lower level of severity.

CVT also initiated community-wide sensitisation, including the commemoration of World Suicide Prevention Day in both camps. These awareness raising campaigns aim to normalise suicidal ideation as a response to trauma and prolonged stress, emphasise that it is possible to recover, highlight the need for community support of those who are in distress and utilise reflective methods, including poetry readings on local radio, art shows at the Healing Centre and candlelight marches through the camp. In addition, recorded psychoeducation and drama skits are provided periodically over the radio, and brochures on risk and protective factors, as well as how to recognise and respond helpfully to warning signs are distributed in the local language.

Capacity Building with Community Partners

CVT developed a capacity building curriculum for partner organisation staff who have regular interaction with UASC, including protection staff, paraprofessional social workers, community police, community mobilizers and teachers. These trainings focus on stigma reduction, communicating with children, understanding observed behaviour as symptoms of distress, providing basic support, recognising risk and knowing when to refer and to where. CVT has also provided training and ongoing supervision and consultation for registration staff operating the reception centre where UASC are housed upon crossing the border, as well as nurses, social workers and refugee “housemothers”. These trainings allow for earlier identification of at-risk youth so that when they are assigned to a camp, the MHPSS centre operating at that camp can be informed and follow up promptly.

Psychoeducation

A developmentally appropriate three-session psychoeducation series was developed for minors once they arrive at the camp, which focuses on emotional awareness, understanding suicide, recognising risk and protection factors, utilising healthy coping strategies and how to get support if you or a friend are considering suicide. CVT provides approximately 50 workshops per year for an annual average of 860 minors, the majority of whom are UASC (see [Table 1]). Following the capacity building activities conducted with refugee social workers, many send the UASC under their care to these sessions soon after arrival. A single-session version was adapted in 2019 to increase accessibility for older UASC and young adults.
Table 1 Psychoeducation Session Participation per Year

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Group and Individual Counselling

The most intensive service CVT offers UASC is a 10-session counselling group, typically made up of 6–8 UASC, grouped by age and gender. These groups are offered to UASC demonstrating moderate to high levels of risk, symptoms and impairment of functioning at intake assessment. The group has three adapted versions according to developmental stage: child, preadolescent and adolescent. The purpose of the group is to provide a structured therapeutic intervention for UASC identified as at-risk, targeting contributing factors to suicidal ideation and building emotional awareness and regulation skills, as well as social support. The group content is structured on Judith Herman’s three stages of trauma recovery (1992) and centres around the story of a child, age- and gender-matched to the group.

The first four sessions focus on safety: safety within the group, emotional awareness and coping with overwhelming emotions, thoughts and physical sensations. During this period counsellors work with clients to develop coping skills that they can use if they become triggered either in session or in daily life. All counsellors are trained to address possible symptom escalation in session and receive live supervision as well as weekly individual and bi-weekly group supervision. The following four sessions focus on remembrance and mourning: making sense of distressing experiences, addressing guilt and shame, attachment rupture, loss and grief, managing anger and self-harm. At this stage, if narrative exposure or processing is indicated, clients will receive this in supplementary individual sessions. The final two sessions focus on reconnection to self and the community: healthy self-talk, visualizing a positive future self and setting practical goals to get there, as well as “good goodbyes”, maintaining social connections and closure. Simplified physical movements drawn from CVT’s physiotherapy work, including “power” postures, progressive muscle relaxation, grounding and polyvagal stretches, sleep hygiene and cardiovascular exercise are incorporated throughout. The group setting has been structured to facilitate social support and the implicit normalisation of symptoms. Home visits for high-risk UASC are also conducted.

Three concurrent psychoeducation sessions are conducted for foster parents and social workers supervising the group homes of children in the counselling groups. UASC are referred to these groups by partner organisations, community leaders, reception centre staff, paraprofessional social workers or following participation in a psychoeducation series. The group manual was piloted for two cycles of six groups: feedback from the field and revisions were incorporated before it went into full use.

Since May 2016, CVT has provided intensive counselling services for 1174 minors, of which 776 were boys and 398 were girls. Most of these clients (78%) complete at least 7 of 10 sessions. Minors, including UASC, involved in group or individual interventions are assessed at intake, and 3, 6 and 12 months follow-ups. Of those who complete the 6-month assessment, an average of 92.5% demonstrate a reduction in psychological, somatic and/or behavioural symptoms of distress (see [Figure 2] for change in symptom cluster by year).
Figure 2 Symptom Reduction Rate by Year

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Crisis Intervention and Postvention

CVT developed and implemented a crisis response programme for imminent or attempted suicide. This initiative provided individual support to the survivor, as well as to the housemates, friends and caretakers, and staff support to humanitarians and first responders where requested (see Box 1 for case study example). Since 2017 CVT has responded to 9–15 UASC suicide attempts per year, and provided postvention support to 8–17 people per response. A supportive, rather than punitive, response to UASC who attempt suicide, as well as a supportive and educational response to their caregivers, is important to reduce risk of re-attempting, and to provide UASC with alternatives to manage their overwhelming emotions. Support to the housemates and rapid screening for risk are important in our context to help limit suicide contagion. CVT also provides bereavement support in cases of death by suicide. This component draws from WHO’s Brief Intervention and Contact and Safety Planning, which was found to be effective in reducing suicidal behaviour in displaced populations (Fleischmann et al., 2008; Haroz et al., 2018; Haroz et al., 2020). Following an attempt, once the UASC has received medical attention, CVT provides home visit check-ins as well as individual counselling. The focus of the counselling sessions depends on the precipitating factors for the attempt, but always includes emotional awareness and management, as well as building additional supportive and coping systems. When appropriate, following the completion of individual counselling, the UASC may be incorporated into a counselling group to decrease the felt isolation and stigma resulting from the attempt.

In 2017, CVT led development of a postvention strategy that engaged all relevant community and humanitarian partners operating in the camps. This strategy aims to ensure timely identification, appropriate referral and coordinated decision making. A simple screening procedure with clear criteria and guidance on risk assessment − including history of suicidal ideation, current suicidal thoughts, plan and access to means − was developed and circulated. The screening procedure was designed to be brief and easy to administer to allow all relevant community and humanitarian partners to strengthen their ability to detect the risk of suicide in children and adolescents. The screening procedure is accompanied by a risk assessment matrix which gives clear instructions for the screener to follow based on risk level. This includes steps to be taken immediately, within the first 24 hours, within the first week and in the longer term. Partner organisations are assigned responsibility for various roles in the response. The postvention was discussed and agreed upon by all parties, and is reviewed annually to adjust for staff turnover or role change among partner organisations.


  Experience and Learnings Top


Our experience in developing and implementing the above programme has resulted in significant lessons learned. While our context has unique factors, many trends are similar across camp contexts, in which minors have been exposed to violence and remain exposed to chronic stress. One of the key factors has been not simply focusing on trauma, anxiety or depression, but incorporating factors related to grief, identity, guilt and shame. This appears particularly important for UASC in displacement, who are negotiating their beliefs about themselves, people in general and the world while navigating exceedingly difficult circumstances with minimal emotional support.

The involvement of caregivers into various aspects of response and treatment is vital. Caregivers whose children were in services were trained on being a safe adult, the impact of trauma on children, common symptoms and expressions of distress, and simple coping strategies that they could prompt and reinforce in the home setting. This enabled them to respond to symptoms and behaviours in a sensitive and therapeutic way, which was more effective and let them feel empowered rather than anxious and reactively authoritarian. After the trainings and psychoeducation, we observed that the caregivers used the material they had learned and worked more clearly from a child-centred approach.

Our experience also suggests that psychoeducation is an important component to support children to recognise their own signs early and understand that help is available and how to access it. We found that the limited emotional literacy common in children was exacerbated in UASC who were not able to benefit from an attachment figure modelling emotional awareness and healthy regulation. This may also be the case with attachment figures who have experienced severe violence and are emotionally dysregulated themselves, such as foster parents or community social workers. The group setting, for both psychoeducation and counselling, provided a supportive and normalising social environment for the UASC, many of whom felt isolated. Utilising techniques designed to connect to a positive self-image and potential future were cited by UASC as helpful in the absence of an encouraging, emotionally present attachment figure.

Incorporating narratives into both psychoeducation and counselling was reported by counsellors to contribute to the effective engagement of community members, caregivers and UASC. Community leaders gave the feedback that when information was presented as dramatised skits on local radio, it caught greater attention and appeared to be more memorable to community members. Similarly, using stories in psychoeducation appeared to effectively engage community member empathy. When used in groups, stories helped to normalize symptoms and allowed UASC to project their experiences onto the character, sharing more in group sessions than when a story was not used. We developed a core narrative for each counselling group cohort (male and female versions of child, preadolescent and adolescent) which could be used as-is or tailored slightly if a counselling group shared particular common experiences, identified in intake. However, we found that it was important to strike a careful balance in which there is sufficient detail to be realistic and to engage listener imagination, while also leaving sufficient space for projection, and not so much detail that the character resembles an actual individual in the community, or is too triggering for the participants.

Adaptation to incorporate aspects of local healing and belief systems into counselling and coping was useful. For example, the use of holy water in our context is common and UASC in distress would sometimes miss sessions to go receive holy water treatments. An adaptation in which use of holy water was incorporated into a grounding exercise appeared to increase UASC buy-in and practice. Normalisation and inclusion of culture-specific experiences, such as stigma related to the “evil eye” was also important. These were often used as example experiences for the character in the story, which allowed UASC to share their own experiences of being ostracized by the community.

Finding creative, not exclusively verbal methods, for expressing complex concepts to UASC was important for comprehension and was adjusted for developmental stage. An example is incorporating a game to demonstrate the importance of confidentiality rather than a lengthy explanation. This took multiple piloting attempts with feedback from the staff implementing the intervention. Embodied approaches to a number of concepts were helpful, including utilising movement and expressive arts as formats that the UASC could use to identify emotion, as well as to cope with overwhelming thoughts or feelings. The use of music as a coping skill appeared particularly impactful. We incorporated an exercise in which different popular songs were played and the UASCs moved around the room using the rhythm, then reflected on how the songs and movement made them feel and how these might be useful or harmful when they are feeling at risk.

In our context, we observed that single gender groups allowed the UASC to feel safer and freer to share their experiences, whereas mixed-gender groups seemed to restrict expressive behaviour to prescriptive gender roles. This may or may not be the case in other contexts.

Challenges have included staff turnover at partner agencies, requiring ongoing training and coordinating to ensure the smooth implementation of the response. Countering the existing stigma has taken significant effort, with a focus on bringing religious leaders on-board, requiring time and investment in relationship building to overcome resistance. Empowering caregivers with skills that they could use when helping minors in distress was effective, but as these were community members managing their own experiences of trauma and chronic stress, effort also had to be put into building their capacity for their own self-care and emotion management. Burnout among care providers at both the humanitarian actor and the community level continues to be a challenge, impacting motivation and capacity for a sensitive response. This underscores the fact that this intervention cannot be one-off in nature, but requires maintenance, with regular awareness raising at all levels.

CVT’s experience in the Tigray refugee camps underscored that the continued stigma and shame surrounding suicide prevented wider discussion and planning among both community leadership and humanitarian agencies. This meant that community and humanitarian partners were ill prepared for the rise in cluster suicide attempts. We anticipate that this is the case in many humanitarian contexts, where the focus on basic needs often results in a lack of attention to the psychosocial pressures impairing the functionality of the population. We recommend initiating sensitive discussions early on in a response, as these are important to help humanitarian actors anticipate barriers, such as stigma, and to facilitate the community in understanding the concept and responding more effectively. It would be beneficial to both service providers and users for standard operating procedures, including a suicide postvention strategy, to be developed, implemented and revised regularly as a matter of course in a humanitarian response. A multidisciplinary team of health professionals, community members, caregivers and MHPSS-oriented humanitarian agencies would be required to develop efficient guidelines. While this may appear resource-intensive, we argue that the current trends in self-harm behaviour among refugees, and particularly minors, justify the worthiness of this investment.

The community leadership and inter-agency coalition continue to provide postvention services. Our organisation is widely recognised by INGO partners and community organisations as a resource for both referral and training, and programming has expanded to include aging-out minors, as well as training for foster parents and other caregivers. Following the recent crisis in Tigray, CVT plans to extend services for UASC to the internally displaced persons (IDP) settings in our area of operation.

Acknowledgements

The work described in this article was made possible by the diligence and sensitivity of the CVT-Tigray team, in particular, Dejen Yewhalaw, Frezgi Gebrekristos, Aida Hailu, Eshete Teshager, Daniel Welday, Adunya Usman, Musie Abel and Abderuhman Kedir. The authors thank Maki Katoh, Shannon Golden, Sarah Peters and Craig Higson-Smith for their support. CVT is grateful to ARRA and UNHCR for their collaboration in the response. CVT appreciates the resilience and ingenuity of our clients who impress us every day with their strength and spirit.

Financial support and sponsorship

CVT’s work in Ethiopia is supported by the Bureau of Population, Refugees and Migration from the US Department of State, by the United Nations Voluntary Fund for Victims of Torture and by private donors. The authors alone are responsible for the views expressed in this article and they do not necessarily represent the views, decisions or policies of the institutions with which they are affiliated.

Conflicts of interest

There are no conflicts of interest.

1Supervised group care: Groups of 6–10 children are placed in a small group home that is run like a family home, supervised by a consistent caregiver, usually a paraprofessional social worker from the community.

2Kinship placements refer to family-based care within the child’s extended family or with friends of the family known to the child, usually as a temporary arrangement for the short-, medium- or long-term.

3Foster placement refers to situations where children are cared for in a household outside their biological family, usually as a temporary arrangement for the short-, medium- or long-term.

4As defined by the National Alliance for Suicide Prevention, a postvention is an organised response in the aftermath of a suicide with one or more of the following three goals: (1) to facilitate the healing of individuals exposed to the grief and distress of suicide loss, (2) to mitigate other negative effects of exposure to suicide and (3) to prevent suicide among people who are at high risk after exposure to suicide (Survivors of Suicide Loss Task Force, 2015).

5Caregivers refers to any adult with recognised responsibility for a child. This could be a parent, biological relative, foster parent or paraprofessional social worker.

Box 1. Postvention Case Study

Feven* was a 17 year-old unaccompanied girl who lived for 4 years in Mai Ayni camp in a community care group home arrangement with five roommates. Feven was separated from her parents and close relatives, although she had an uncle in the same camp.

According to her roommates, Feven struggled with the protracted separation from loved ones and homesickness, and wanted to seek care and comfort from others. She began to spend time with a young boy, but this made her uncle unhappy. The uncle repeatedly reprimanded her to stop and once beat her hard for disobeying. As pressures from the uncle continued, Feven decided to obey him, but this then caused a fight with the boy. Feven then quarrelled with her uncle for his abusive treatment.

The cumulative stressors from the separation from her parents, as well as the lack of support from her uncle and boyfriend, were challenging for Feven to deal with. She expressed feeling lonely to her friends as well as immense feelings of anger and hopelessness. She became irritable and aggressive with her roommates. Her friends reported that she began to drink alcohol in the evenings. The roommates informed the supervising social worker about Feven’s change in behaviour. The social worker tried to help by giving her advice, but there was no improvement. The social worker did not link Feven to mental health or other services for additional support.

One day Feven waited for her roommates to leave to wash their clothes. Once they were gone she poured kerosene over her body and set herself on fire. The neighbours heard the screams of pain and tried to help. However they were too late. Feven was rushed to the refugee health centre and from there she was referred to the local hospital and then on to the regional hospital. However, it was not possible to save her life.

CVT responded 24 hours after the incident. The primary activities were:
  • In collaboration with the community social workers, CVT counsellors attended the memorial service to pay their respects. They then made a home visit to Feven’s house, where they held a group session focused on de-escalation and emotional regulation with the roommates, and addressed some of the feelings of guilt and self-blame associated with the crisis.
  • Feven’s roommates were given individual psychological first aid (PFA) and screened for risk level.
  • Individual PFA was also provided to the social worker supervising the group home, Feven’s uncle and the neighbours who witnessed the incident.
  • Two of Feven’s friends identified as being at heightened risk received individual counselling sessions to process their grief and feelings of hopelessness and guilt.
  • CVT conducted psychoeducation sessions with UASC in the surrounding group homes, as well as with the community social workers and other members of the community. During these sessions counsellors watched for potential warning signs of risk and need for more intensive follow-up.
  • Coffee corner discussions were facilitated for community leaders in that zone of the camp focused on early identification of warning signs for suicide and referral pathways.


*Name changed to protect client confidentiality.







 
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