Confronting Trauma in Marawi, Mindanao, Philippines

Preliminary summary report of the GIST-T rapid psychosocial needs assessment 5-15 January 2018

Setting

On 23 May 2017, affiliated militants of the Islamic State (IS), including the Maute and Abu Sayyaf Salafi jihadist groups, launched an attack on the Philippine government security forces in Marawi, Mindanao, the country’s largest Muslim-majority city. It was a planned effort to establish an ‘IS province’ in the Philippines. Government troops took an unexpected five months to liberate Marawi, at a cost of near-total destruction of the old city and displacement of some 350,000 citizens (who became ‘internally displaced persons’, or IDPs), plus more than 1,000 dead. Then, on 22 December 2017, tropical storm Tembin (known as Vinta in the Philippines) struck Mindanao island and turned another 100,000 people, already living in the IDP reception areas following the violence, into new IDPs, and also added several hundred dead. It was a visitation of injury upon injury, external and internal, which will take years to reconstruct and heal.

Figure 1 Marawi’s main street, January 2018

Needs assessment

In response to these events, a five-member GIST-T team, in consultation with EMDR Philippines, Philippines Psychiatric Association, Nonviolent Peaceforce (NP) and World Bank Manila, conducted a needs assessment to understand the psychosocial impact of the recent crises in Marawi on the affected population— individuals, families, and local

communities. The aim was to gather first-hand information from IDPs, review the state of current psychological services available, identify unmet mental health needs, and propose immediate and medium-

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term ways to strengthen capacity of mental health professionals and paraprofessionals to provide appropriate treatment.

The team interviewed some 120 people, including 80 IDPs for psychometric screening using eight standardized instruments (in four Evacuation Centres and as ‘Homestays’). Others interviewed were 20 humanitarian workers, eight teachers, three psychiatrists and two military commanders. Focus Group Discussions were held with an additional 30 local actors closely associated with the events. This preliminary summary represents a work in progress, since over 600 data sheets, containing rich qualitative data, remain to be analyzed.

Figure 2 Gail Womersley, center in grey, with a focus group of Marawi teachers and two NP colleagues

Representativeness?

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Topline findings

Mindanao presents a multidimensional context of complex trauma in which all the ‘Four Violences’ are present and recur in a predictable pattern: direct violence, which is intended; the violence of nature, which is unavoidable; structural violence, which results from built-in inequalities; and cultural violence, based on deeply-held beliefs concerning power and violence

Significant levels of trauma were observed among, and/or self-reported by, IDPs as well as frontline responders

Our purposive sample was highly symptomatic of anxiety, Post-Traumatic Stress Disorder (PTSD), and clinical depression

However, current interventions are not addressing the population’s traumas. Instead, interventions are merely ‘psychosocial’, mostly based on Psychological First Aid (PFA), and hence seriously inadequate to provide trauma relief

An urgent need exists to provide appropriate, WHO-recognized trauma therapies to selected individuals and groups

four GIST-T Marawi Mission members together with the

The rapid assessment, conducted over a five-day period with the help of four interpreters speaking English, Maranao, Bisaya, and Tagalog, limited itself to parts of the two Lanao provinces. Given these cultural/linguistic challenges, time restrictions and geographical limitations, the results cannot claim to be representative of the whole community.

Even so, involvement of local partners allowed the mission access to a wide range of key stakeholders and to a surprising depth of people’s emotions and experiences. Topics raised were often controversial, culturally sensitive or religiously taboo: issues surrounding suicide, rape and forced marriage, suspected looting by the military, sympathies with ISIS, antipathy towards the Government’s armed forces, corruption.

A context of complex trauma

The data highlights the fact that the recent Marawi crisis is not an isolated traumatic incident or event. Rather, it reveals a context and pattern of deeply-engrained complex trauma dating back generations, related to:

Historical and intergenerational trauma Intra-familial trauma, including Rido Endemic political violence Violent extremism Sexual Gender-Based Violence (SGBV) Natural disasters History of forced evacuations/displacement

Furthermore, the current context is characterised by long waiting lists for resettlement, the impossibility for many to return to their homes, increased reports of SGBV and of young women sent away to Manila and elsewhere to earn money as commercial sex workers, rising tension among IDPs and host communities, and a risk of compassion fatigue among host communities and even engaged humanitarian actors. All of this increases the risk of polarisation and violent extremism. This is a critical consideration for the mental health of this community, given the role that exposure to complex trauma may play in the cycle of violence, abuse and aggression.

The state of current psychosocial services available

The psychosocial interventions currently being implemented are almost entirely ‘social’ – that is to say, based on interventions on the first, second and third layer of the Interagency Standing Committee (IASC) mental health Intervention Pyramid (addressing social needs at a community level—see Figure 5, below), yet not on the fourth, top layer of the pyramid (more acute psychological needs). This includes a noted reliance on PFA - a necessary, but insufficient intervention to deal with PTSD and other trauma-based disorders. The Mental Health and Psycho-Social Services

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Figure 4 Gail Womersley with interpreter Ameena and an IDP

(MHPSS) cluster of humanitarian actors in Mindanao has now been deactivated, demonstrating the lack of available psychological services available to the population.

The key actors implementing psychosocial activities based on PFA include Médécins Sans Frontières, the six social workers of the Social Welfare and Development, Balay Rehab (a local NGO), the Military (under the supervision of two military psychologists based in Manila), and the 1200 teachers from Marawi who have been trained in PFA by the Department of Education. None of these actors have a certified clinical psychologist currently working directly with the population.

All of these actors report sporadically referring more serious cases to the two psychiatrists based in the area (of which one works for the Department of Health, and the other in private practice, both in Iligan). However, two professionals alone cannot address the widespread psychological needs of this population.

Quantitative findings

Below are the quantitative results from the GIST-T assessment of January 2018 among 80 IDPs.

Anxiety: Results of the GAD-7 score

Nearly half (49%) of the IDPs screened for anxiety could be diagnosed with severe anxiety warranting a specialist referral to a psychiatrist.

Depression: Results of the PHQ9 score

Nearly half (46%) of the IDPs screened for anxiety could be diagnosed with severe depression warranting initiation of pharmacotherapy and psychological treatment.

PTSD: Results of the PCL-5 score

At least 78% of the IDPs screened meet the criteria for PTSD.

Early Childhood Adversity: Results of the ACE score

The population of adult IDPs who were screened have been exposed to a high number of adverse events in childhood, such as abuse, neglect, violence and poverty. The average individual screened had been exposed to around three different adverse events in their childhood.

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Summary of quantitative results (N=80)

71% had Moderate to Severe features of Anxiety Symptomatology

80% had either Moderate or Moderate to Severe features of Clinical Depression

78% met the DSM-5 Criteria for PTSD

Mean ACE’s score: 3.09

Figure 5 IASC Intervention Pyramid

Results of preliminary data obtained in June 2017

An earlier preliminary study, conducted by the Philippino mission member, was undertaken among 25 home-based IDPs soon after the ISIS takeover of Marawi. Different instruments were used. However, this study similarly revealed high levels of mental health problems among this population. Out of the 25 individuals screened:

64% met the criteria for clinical depression/anxiety (according to the Hopkins Symptom Checklist)

31% met the criteria for PTSD (according to the Harvard Trauma Questionnaire)

Discussion

There is a significant level of psychological distress among this population. The vast majority of people from the area was visibly affected by events and circumstances. This is unsurprising, given the recent crises in Marawi, as well as the history of complex trauma to which the population has been exposed. It is, however, a cause for serious concern, given the integral role that trauma itself plays in the cycle of violence, abuse and aggression, namely as a driver of conflict and cause of further traumas.

Serious symptoms of depression, anxiety, and trauma were clinically observed by the four consultant psychologists/mission members—confirming the results of the psychometric screening. Among the most disturbing observations was the increase in physical violence and aggression reported— particularly among the youth. Children, for example, were seen to play ‘ISIS-ISIS’— dressing up as military and ‘re-enacting’ the traumatic events to which they had been exposed. Others were too afraid to attend school— jumping at the slightest sound of a motorcycle or a helicopter, as the noise would trigger memories of the trauma. Similarly, the emotional distress among adults affected their ability to complete everyday tasks and to function productively.

The majority of actors with whom the team engaged, including the military, teachers and humanitarian workers, spontaneously referred to themselves needing psychological assistance for their own trauma— with some becoming visibly emotionally distressed/in tears when speaking about their experiences. Despite the stigma surrounding mental health in general, many spoke directly and openly about their psychological distress and need for assistance. Their receptivity is a very positive factor. Quantitative results of psychometric screening, qualitative data obtained from interviews as well as clinical observations unequivocably point to this being a traumatised population. It is also apparent that current psychosocial interventions are inadequate to fully address their needs.

Next steps

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Figure 6 Fr. Cornelio Jaranilla interviewing an IDP.

The mission is in the process of designing a three-phase project to address these needs. First, to offer immediate EMDR treatment to up to 100 high-priority victims of the Marawi/Tembin crises, including 41 hostage survivors (half of them minors) and affected humanitarian workers. Second, to strengthen the capacities of local mental health personnel available, willing and able to be trained to deliver EMDR treatment for traumatized IDP populations living in camps in the Lanao provinces. Third, to create local EMDR treatment capacity through large-scale training throughout Mindanao.

While the first phase activity could start within a month upon confirmation of funding and last up to nine months, the second and third phases would be designed in parallel, identifying implementation partners, creating coordination framework, budgeting implementation costs, and raising funds. Implementation could begin in 2019 and 2020, respectively.

A strong evaluative research component would be built in with support from the Mindanao State University plus a modicum of international assistance to ensure adherence to global standards. Widespread use will be made of translators/interpreters. Several innovations are foreseen, including the introduction of EMDR Early

Intervention (EI), involvement of non-specialists and paraprofessionals, rapid PTSD assessment methods using mobile phones, and on-line teaching-and-learning

in self-care and peer-to-peer support. A twinning arrangement between Worcester University and Mindanao State University will also be considered with the aim to build capacity for an EMDR MSc program.

Various types of violence cause traumas with often devastating consequences for individuals, families and societies as a whole. It holds back human development, social development and economic development. And trauma itself can also become a driver of violence. The GIST-T team saw that being played out in Mindanao. Unless these multiple traumas are treated, prospects for progress and peace in Mindanao are dim. UNESCO’s adage: ‘Since war begins in the minds of men, it is in the minds of men that the defenses of peace must be constructed’ reminds us of the imperative of psychological health for peace and development.

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Figure 7 Dr. Derek Farrell supporting Fr. Chito who returns to Marawi for the first time since his four months’ hostage ordeal, here seen entering his bombed cathedral.

Figure 8 Dr. Sushma Mehrotra speaking with an IDP...........