Yemen – living with trauma

"I'm handicapped inside", says Ahmad, who in October 2011, aged 15, was shot and injured in street protests against the government in Yemen's capital Sana'a.

The wound left him with a limp, and deep psychological scars. After struggling for a year with the mental trauma from that day, he sought help at the city's al-Amal Hospital for the Treatment of Psychological Illnesses.

"It's like a nightmare and I feel psychologically disturbed when I pass [by] the street I was shot in. It's really bad," Ahmad told IRIN.

The violent protests that eventually led to the end of President Ali Abdullah Saleh's 33-year rule have left a legacy of trauma in a country with very little in the way of mental health services.

The latest government figures indicate there are "44 psychiatrists out of 8,534 specialist doctors in the whole country", though these estimates date from 2006. At about one psychiatrist per 500,000 people, the statistic reflects one of the lowest psychiatrist-to-patient ratios in the Arab world. Apart from Al-Amal, there is only one other major treatment centre for mental disorders - the Al-Salam psychiatric hospital in Aden.

"The Ministry of Health [and Population] focuses on bodily diseases to the detriment of mental illness," one medical coordinator at an international humanitarian agency in Sana'a, who asked not to be named, told IRIN. "The ministry doesn't keep records of how many mental health professionals there are in the country because they don't know."

Ayed Talha works as a psychiatrist at al-Amal Hospital where he treats Ahmad and a number of other patients.

"In recent years we started seeing a lot of children suffering from the consequences of trauma. The majority are the result of war," he told IRIN.

"It is now well established that children exposed to trauma are more likely to become aggressive later in their life when they become adults… so we'll have a crippled society at the end of it if we don't give them the appropriate care."

Daily stress

Even for those not directly affected by the recent violence, a shrinking economy and high food prices have added to the daily stress of life for many families in Yemen, a country in which nearly half the population are food insecure.

"There's a sense of hopelessness in Yemen's poverty," an administrator and doctor at a neurosurgery hospital in Sana'a, told IRIN.

With the dearth of mental health facilities, Yemenis rely on family and other traditional support networks, the doctor said.

"It's like in psychological treatment. The doctor asks you to find a support community to go to; Yemeni families don't let you feel like you're all alone and have to go through the pain alone."

"I became different from the way I was before. In the past I was happy, but now I am not", Amira, 12. Meanwhile, NGO mental health services are concentrated on refugees, migrants and internally displaced persons (IDPs).

The International Organization of Migration offers psychosocial counselling services in Haradh, Hajjah Governorate, in the north of the country. In the south, INTERSOS provides psychosocial support for the most vulnerable IDPs returning to Abyan. Handicap International offers rehabilitation and psychosocial services for disabled victims of landmines and unexploded ordnance in Aden and Abyan; and for the past four months Médecins Sans Frontières (MSF) has been implementing mental health programmes for migrants detained in Sana'a before being deported. Currently about 10 percent of the 500-600 migrants are receiving treatment.

Group therapy with khat

Some find solace in the ritualistic chewing of khat, an amphetamine-like drug consumed at the end of each day by most Yemeni men, and 30-50 percent of women.

In Sana'a, an influential tribal sheikh whose family opposed government forces in 2011, likens khat sessions to "group therapy", where fellow revolutionaries can reflect on shared trauma. For many Yemenis, it is the closest they will get to being "in treatment".

Dependency on the stimulant, however, has an economic cost, especially when household budgets are tight.

Meanwhile, those able to access professional psychiatric care at al-Amal Hospital do seem to benefit.

Amira, 12, was at home when a shell blew up a neighbour's house, killing her three-year-old sister. "I became different from the way I was before. In the past I was happy, but now I am not." Nevertheless, she has returned to school following treatment.