Increasing violence and a new round-the-clock curfew imposed last Sunday in Jammu and Kashmir, India, led the international medical humanitarian organization, Médecins Sans Frontières (MSF) to halt its mental health activities in the Kashmir Valley. This strict curfew is in place in several parts of the state. No person without a valid curfew pass is allowed outside their house. Sometimes curfew passes are not honoured. Road blocks are numerous, shops are closed and the streets are empty.

Mental health first aid

The recent violence adds to the heavy toll already on people traumatised by two decades of conflict and civil unrest. Patients with gunshot wounds and tear-gas shell injuries are treated in the hospitals in the main city of Srinagar, but while their physical injuries are being treated, many also have psychological needs.

With the cooperation of hospital staff, since February 2010, MSF counsellors have been visiting patients in the hospitals and offering on-the-spot psychological assistance to victims of violence and their families.

“We are calling it mental health first aid,” said MSF’s Project Coordinator Sasha Matthews.

Counselling sessions halted

But with the new curfew - ongoing now for six days and the general security situation, MSF teams have had no access to the hospitals to continue conducting the counselling sessions.

“MSF is extremely concerned about how this deteriorating situation will significantly affect people and their mental health,” said Martin Sloot, Head of Mission for MSF in India. “Our national staff has been confined to their homes. We have relocated our international staff to a safer place.”

The latest surge in violence began in June, 2010, when regular street battles between Kashmiri youths and the Indian security forces intensified. Hundreds of people were injured and more than 90 civilians killed. The Kashmir Valley has seen around 85 days of curfew since the end of June, so leading a normal life has become impossible.

Violence is nothing new in the region

Militants and Indian government forces have been fighting each other since 1989. Ordinary people have been caught in the middle and have been the victims of serious human rights abuses committed by both sides. During the course of the conflict, many thousands of people have disappeared and tens of thousands been killed.

In an effort to crack down on the militant insurgency, the Indian government has flooded Kashmir with troops. There are currently an estimated 600,000 soldiers in the region. The military presence is everywhere.

“Every public space – schools, stadiums, cinemas, markets, everything – has been taken over by the security forces,” said Matthews. “There’s razor-blade barb wire across the valley. Every day you see hundreds of military convoys and security forces patrolling the streets. For ordinary people, there is this constant visual reminder of their presence.”

For two years, young men had been throwing stones at the soldiers after Friday prayers.

“The stone-pelting almost became a ritual,” said Matthews.

Earlier this summer, it turned deadly when the soldiers responded with force. People on both sides were injured and civilians were killed.

The program: Mental Health First Aid

Explaining the rationale behind mental health first aid, Matthews said, “It is a method of enhancing the patient’s own natural coping strategies after they’ve suffered a traumatic event. We help them to use their own self-healing process successfully.

“The counsellors provide emotional support by listening to the patient’s stories, help them to come to terms with what has happened, and offer practical advice on how to deal with possible psychological consequences. Overall, the major goal is to give emotional support to all victims of violence and their families with a caring and practical approach and a neutral and non-judgmental attitude.

“The counsellors return to carry out between three to six follow-up sessions; and are welcomed back, despite the stigma so often associated with mental health issues in Kashmir. The patients react positively to our presence.”

Since the program started in June, MSF has provided mental health first aid to over 600 people.

Matthews tells the story of a boy, 13, in the hospital with his second gunshot injury. In front of his friends and family, he was adamant that he did not need support from a counsellor.

“He said, ‘I’ve been injured before and I can cope with it’, said Matthews. But when the counsellor returned later when the boy was alone, he was grateful to be able to tell his story and receive professional help.

MSF teams have provided psychological support to patients who are Indian security personnel also injured in the recent violence. One counsellor was approached by a patient who said, “I’m so happy to see you – you saw a colleague and friend of mine a few days ago, and he advised me to talk to you.

MSF has been providing a wide range of mental health services in Kashmir since 2001, and particularly mental health first aid, for the past six months.

“This new strategy has now become a regular activity and the only type that we can carry out when the context is this volatile,” said Matthews.

MSF history in Jammu and Kashmir MSF

has worked in Jammu and Kashmir since 2001 offering psychosocial counselling to a population traumatized by over two decades of violence. In 2009, MSF’s mental health program treated more than 5,800 people. MSF also provides psychosocial education to the people of Kashmir through various means, including the MSF radio show about mental health called “Alaw Baya Alaw” (“Call Brother Call”). In addition, MSF provides basic healthcare in seven clinics in Kupwara, conducting more than 20,500 consultations in 2009. Over the years, MSF has carried out several emergency interventions in response to natural disasters and epidemics in India. Most recently, MSF responded to the flash floods in Leh and Ladakh.