Commit and act on Ebola

Since March this year parts of West Africa have been ravaged by the Ebola virus, several thousand people have died, and the World Health Organization has come under fire for not acting quickly enough. But in addition to practical and humanitarian challenges, such as screening and quarantine procedures, the epidemic raises psychological ones too. In a remote part of Guinea, eight aid workers and journalists were reportedly murdered and dumped in a latrine, with the BBC claiming that many villagers have accused the health workers of spreading the disease. Behaviours which are ingrained in local culture, such as burial customs which involve close contact with the deceased, have also fallen under the spotlight.

So is there a role for psychologists to work with communities in these regions to increase acceptance of health workers, adapt burial rituals and support people whose communities have been torn apart by the disease? We spoke to one organisation involved in this work.

In January 2014 a mental and behavioral health clinic opened in Bo, Sierra Leone, under the name 'Commit and Act'. Germany-based Clinical Psychologist and ACT advocate, Beate Ebert, had been inspired to help people in Sierra Leone in 2009 after hearing about the great trauma suffered by people following the vicious long-term civil war in the country. She founded a not-for-profit organisation which trains people in Acceptance and Commitment Therapy (ACT), a so-called 'third wave' approach combining mindfulness and acceptance with behaviour change.

Their organisation's firm grounding in the country and familiarity with local people has meant commit and act have become instrumental in tackling Ebola, its spread, and the horrific psychological impacts of the disease. Beate said: 'We believe that horror scenarios painted in the media, a culture of fear and purely biomedical interventions, won't solve the crisis. Prevention is key, and prevention requires effective behavioural change. Prevention is cheaper, more effective and can create lasting positive changes and enable people to face the future crises.'

'They thanked me for listening to them'

Beate was first inspired to help the people of Sierra Leone after hearing a vivid talk from half Sierra Leonean Sarah Culberson, who had been adopted by a middle class American family. Beate was shocked to hear of the vicious civil war in the country and had first intended to visit during her holiday time to provide counseling to those who had suffered trauma following the war. However, health workers in the country advised her that this may not be useful as she did not speak the local language and people needed long-term support. Beate said: 'So, the idea came up to train local counselors in the practical behavioral therapy method I learned, Acceptance and Commitment Therapy. I thought it should work well for people there, as you can deliver it in an experiential way and adapt it to all kinds of problems.'

Beate visited Sarah's father in the country and met people living in remote villages. Many had no idea what a psychologist was but they were grateful that somebody was coming from outside, that somebody was interested in them. Beate said: 'I met people in the amputee camp, their limbs had been cut off by rebels in the war. They told me their life stories and it was heartbreaking how vulnerable they were, trying to deal with their impairments… They were obviously starving, left with no support from the government and with no psychotherapeutic support at all. They thanked me for listening to them and asked me to spread their message so they would not be forgotten.'

Beate found powerful partners in Father Peter Konteh from Caritas, Freetown, and Dr Ross White from the University of Glasgow, deputy chair of commit and act. Dr White has visited Sierra Leone twice in recent years as an ACT trainer and has also been involved in supervising MSc Global Mental Health students who have visited Sierra Leone and conducted their MSc research projects there. Beate said upon initial news of the Ebola outbreak members of commit and act gathered to discuss how they could best help mitigate the impact of the disease and prevent its spread. 'We made a deliberate effort to adapt the ACT model to the Ebola crisis by using it as a tool to initiate behavioural change. We also contacted the founders of the PROSOCIAL and the Acceptance and Commitment Approach, David Sloan Wilson and Steven Hayes, who both kindly and generously support our work.'

Hannah Bockarie, a Sierra Leonean social worker, teacher and counselor, and the organisation's current local director, has been leading ACT workshops in her local language Krio since 2013. She now shows a video in large community meetings which explains what the Ebola virus is and how it spreads. She uses the PROSOCIAL approach to find solutions for more hygienic behaviour that prevents new infections, but still allows people to follow their traditional burial ceremonies, which is very important for them.

Beate explained that simple, clear information is vital. She said at the start, Ebola was believed by many to simply be a rumour and when people started dying, it was thought that the government was trying to kill and weaken its political opposition in the East and South of the country. Given the violent recent history of the country, such rumours are created by fear and mistrust in politics.

Since the outbreak of Ebola Hannah has been promoted to head of psychosocial care in the Ebola prevention campaign and works in Bo, Sierra Leone. She said: 'We have been able to educate thousands of people in the area of Bo and other chiefdoms; Bo, where we mainly operate, is the only area where the increase of new infections slowed down considerably, according to the numbers provided by the Ministry of Health and Sanitation… It's hard to prove, but we believe it has to do with our efforts, in collaboration with the Ministry of Health and Sanitation and other NGOs.'

Fear of medical workers

Despite reports of aid and medical workers being killed or injured in some parts of West Africa while responding to the Ebola outbreak, Beate said: 'Even as Westerners, whenever we have worked in the country, people have been exceptionally warm and welcoming, and appreciate the time and effort we put in to our work. It seems that problems and conflict arises when ex-pat staff work in remote areas which they have not been before where there is no relationship with people, they don't know them and vice versa. Don't forget, in a post-conflict country, trust is important. When medical staff appear in hazmat suits, or "space suits", local people are simply frightened by what they have never encountered before… that is just a natural reaction. And if these strangely clad foreigners then give orders and tell you how to behave, skepticisms and fear are high and problems arise.'

The commit and act counselors have been supporting people in rural areas who may not be familiar with medical staff. Health workers called in Hannah Bockarie to help them with a man who had potentially been infected with the virus. He had become violent and rejecting blood samples to get tested. Beate said: 'Hannah talked to him and counseled him, realising he was deeply scared. She asked him what was important to him, and he said he wanted to be healthy again. Hannah then explained how taking a blood sample could help much, much better to achieve this goal of getting healthy. So, after the counseling session he agreed to have the blood test taken and cooperated fully. The medical staff were deeply impressed with Hannah's work.' 

Kissing the banana tree

One major cultural difference which is impacting on the spread of Ebola in West Africa is the differing burial rituals used in some communities: bodies are usually washed then laid in the home for family members to pray over, kiss and pay their last respects. These rituals, Hannah explained, matter deeply to the grieving family and without them they will feel disconnected from the community.

Beate explained that the counselors in the country have used a PROSOCIAL matrix process to help people to change these burial rituals in a way which is acceptable to their culture. She said: 'This matrix helps them develop a willingness and acceptance that they are not avoiding the pain, but going through the pain of not completing the traditional rituals and using alternative rites instead. By highlighting how the new behaviours align with their core values – to take care of their living family and community – participants are willing to accept and commit to the changes in their behaviour. One great example is that they use the trunk of a banana tree instead the dead body to do the traditional burial rituals. We could never invent such an idea as Westerners. PROSOCIAL is a simple concept, but not that easy to convey and very effective when done properly.'

The future

commit and act is training 50 new psychosocial assistants in how to conduct community meetings and deliver solid and clear information about the virus potential behavioural changes. In Bo, one of the quarantined locals, Brima Sowa, said about the work of commit and act's psychosocial assistants: 'They have brought hope, happiness, joy and send us back to our lost glory. It has been very difficult to have people to talk to us even our relatives, friends and our neighbours. With the advent of the psychosocial Assistants we have gained hope, they were talking to us, encouraging us and they advocated for us at the Emergency Operation Centre and our voices were heard through them.'

Resources

www.commitandact.com

For more on the changes in burial rites see this article from the Huffington Post.

Ebola clinical psychologist: 'How I help NHS staff cope in Liberia'. Plus more from the same psychologist.

Vice article on the human causes of the continuing outbreak.

Up-to-date information from the WHO http://tinyurl.com/saydk

BBC Ebola page.