Psychosocial Support for Bhutanese Refugees in Nepal

Reiffers et al.

Psychosocial support for Bhutanese refugees in Nepal

Relinde Rei¡ers, Ram Prasad Dahal, Suraj Koirala, Renee Gerritzen, Nawaraj Upadhaya, Nagendra P. Luitel, Shaligram Bhattarai & Mark J.D. Jordans

For more than 20 years, thousands of Bhutanese 80,000 Lhotshampas were forced to £ee refugees have been living in refugee camps in eastern to Nepal following the introduction and Nepal, in an uncertain and challenging situation. enforcement of restrictive citizenship laws, Now, the possibility of resettlement is bringing even and a ‘One Nation, One People’ government more challenges into their lives. In recognition of this policy (Hutt, 1996). Bhutan claims that this situation, the nongovernmental organisationTrans- group left willingly and denies they were cultural Psychosocial Organisation Nepal provides ever citizens. The refugees, however, claim psychosocial support to this group, in collaboration that they were forced to leave Bhutan withUnited NationsHighCommissionforRefugees because of their ethnicity. As a consequence and other humanitarian agencies.This ¢eld report of this process, many people have lost their providesanoverviewofthepsychosocialissues,inter- nationality and are currently stateless. The ventionsand implications,as wellaslessonslearned. government of Nepal, concerned about the It also includesthe casestudyofa refugee. Direct psy- implications for national security, has not chosocial support, psycho-education and capacity beenwilling to allow the refugees permanent development are major elements of the programme residence.Yet, even though Nepal is not a sig- provided, notonlyto refugees,but alsotothehost com- natory to the 1951 Refugee Convention, the munity and aid workers as well. Recommendations government has allowed the refugees to live include: continuing and strengthening services for ‘temporarily’ in refugee camps (Adelman, both refugee and host communities, increasing atten- 2008). From 1993, until now, there have been tion to vulnerable groups (such as the elderly),and 14 bilateral negotiations between Bhutan enhancing links and cooperation with local and and Nepal to ¢nd a sustainable solution, international services and structures. but these have all been in vain (Sharma, 2009). Due to increasing international Keywords: Bhutanese refugees, multi- discussions on the ‘warehousing’ of refugees leveled support system, Nepal, protracted (a situation where refugees are housed in displacement, resettlement one place for years on end due to lack of agreement or decisions on how to resolve the situation), as well as donor fatigue, some Introduction international community members have The relationship between the northern agreed to facilitate a process of resettlement Bhutanese (Drukpa) and southern Nepali- to the United States, Canada, Australia, speaking Bhutanese (Lhotshampas) popu- New Zealand, Norway, Denmark, the lations was relatively free of con£ict until Netherlands and the United Kingdom the early 1990s. At that time, more than (Loescher & Milner, 2005).

169 Copyright © War Trauma Foundation. Unauthorized reproduction of this article is prohibited. Psychosocial support for Bhutanese refugees in Nepal Intervention 2013, Volume 11, Number 2, Page 169 - 179

Under the resettlement programme, which 2008 (Prasad Dahal, 2011). Since then, TPO was launched in 2007,more than 50,000 refu- Nepal implements the Psychosocial Support to gees from Bhutan have now left Nepal to Bhutanese Refugees in Camps project, with the start a new life elsewhere. The United aim of improving psychosocial wellbeing Nations High Commission for Refugees and reduce psychosocial distress among (UNHCR) and partner organisations con- Bhutanese refugees. In order to achieve this, tinue to seek solutions for the remaining TPO Nepal works in close coordination with 60,000 refugees. According to UNHCR, UNHCR and camp based organisations more than 49,000 people among the remain- (CBOs) from the refugee community1 to ing refugee population have expressed an provide a range of psychosocial support to interest in resettlement (http://www.unhcr. address psychosocial distress, with attention org/pages/49e487856.html). to cultural values2. This report provides an Other refugees, however, do not want to overview of these psychosocial interventions leave the area and prefer to either repatriate over the last three years and re£ects on to Bhutan, or stay in Nepal. The inter- achievements, the ongoing needs of the refu- national community hopes that Bhutan gees, and lessons learned. and Nepal will allow these smaller groups to either remain or return, as humanitarian Psychosocial issues in the interventions are planned to be phased Bhutanese refugee camps out after conclusion of the resettlement A need assessment among Bhutanese programme. refugees in the camps showed that they In the meantime, international and national experience various contextual stressors humanitarian agencies continue to provide related to basic needs and shelter, as services related to health care, education well as resettlement opportunities and and other needs within refugee camps in procedures (Luitel et al., 2009). According Nepal. There were originally seven camps, to this assessment: ‘fear and insecurity, con£ict but due to the resettlement process men- in the family, confusion, substance abuse, stress tioned above and the consequent decrease and anxiety, worry about culture and religion, fear of the refugee population, camps are now of separation and suicidal ideation are some of being consolidated. Conditions in the camps the key psychosocial problems prioritized by remain challenging; they are overpopulated respondents in the focus group discussions’. andthere are security risks related to con£ict Another psychosocial needs assessment and violence. Continuing uncertainty about identi¢ed suicide as one of the major the future and a protracted stay in the camps problems present, and con¢rmed that the has also fuelled frustration and distress, number of suicides among Bhutanese refu- which inturn impact psychosocialwellbeing. gees in Nepal is disproportionally high In order to o¡er the refugee community (Schinina' et al., 2011). psychosocial support, the UNHCR has Living in a refugee camp for 20 years, after begun to work in cooperationwith theTrans- having gone through di⁄cult experiences cultural Psychosocial Organisation (TPO) and without any clarity in terms of the Nepal. The involvement of TPO Nepal in future, creates many challenges. For years, the refugee camps began in the aftermath many refugees hoped to either return of a large ¢re that a¡ected a major section to Bhutan, or stay as residents in Nepal. of the refugee population in two camps, in However, given the complex relationship

between Bhutan and Nepal, this has proved Psychosocial care programme impossible to date. While there are edu- The psychosocial care programme aims to cational and medical facilities in the camps, enhance community resiliency at grass root and refugees have been able to organise level with wider participation of the refugee themselves within various forums and con- community in the design and implementa- tribute to activities for others in the camps, tion of activities3. The programme includes: giving meaning to life has proved to be awareness raising to increase mental health di⁄cult. Additionally, as refugees they are literacy in the community, psychosocial not o⁄cially allowed to work and therefore, counselling, classroom based interventions, unable to provide for their families. Even and group interventions, such as women’s so, some of them do work as farmers, trades- empowerment groups. For interventions on men, tailors or teachers in the informal specialised mental health care levels, people sector, or within the camps. are referred to other specialised aid agencies. Resettlement to third countries does Interventions are assessed and adapted provide an opportunity to study and work, based on research (Figure 1).4 and with that hope. This new dimension, Fifteen psychosocial counsellors parti- however, has created complex situations cipated in a training course on psychosocial for families.Young people are eager to start issues and support. They now provide a new life and create a better future for psychosocial counselling in counselling themselves and their children. However, centres in the camps, or in people’s huts. many elderly people have no wish to The counsellors are supported and super- migrate again and prefer to wait for an vised by clinical psychologists. In order to opportunity to either return to Bhutan or strengthen early identi¢cation of psycho- stay in Nepal. Within families, this has social problems, ensure timely referrals and created tension and con£ict, resulting in provide suitable care, members from the some people either migrating or staying refugee population have also been trained against their wishes. Families can be separ- to work as community psychosocial workers ated for years, because part of a family (CPSWs) and/or Classroom Based Intervention may be eligible to resettle, whereas others (CBI) facilitators. Eighteen CPSWs and have to wait for completion of a long process 12 CBI facilitators provide basic psychoso- due to complicating factors, such as: severe cial services.Their presence is advantageous (mental) health problems, divorce, or as it creates a continuous presence of know- mixed marriages between refugees and ledgeable and supportive people within the local people from Nepal or India. camp. Ongoing uncertainty and family con£icts Counsellors are involved with psychosocial may also lead to various psychosocial prob- counselling, psycho-education, and aware- lems, such as depression, suicidal ideation ness raising campaigns, assisted by CPSWs. or suicide. Sometimes, there are weekly They help people to deal with their reports of attempted or committed suicides problems, and support them in ¢nding by refugees who can see no other way out. new ways to cope. Main components of Di⁄culty in giving meaning to one’s life, or psychosocial counselling include: problem dealing with problems, can result in other solving, symptom management, psycho- negative impacts, such as substance abuse education, emotional support in relation- and/or an increase in domestic violence. ships, and development of personal skills.

171 Copyright © War Trauma Foundation. Unauthorized reproduction of this article is prohibited. Psychosocial support for Bhutanese refugees in Nepal Intervention 2013, Volume 11, Number 2, Page 169 - 179

Mental health referral Specialised services

Substance disorder care Focused, Psychosocial counselling non-specialised Individual counselling supports

Group interventions

Community and family supports Classroom based interventions Women's empowerment groups

Awareness raising Basic services and security Psycho-education vulnerability assessments Screening community resiliency building

Figure 1: Psychosocial intervention framework for Bhutanese refugees in Nepal

Family-oriented supportive counselling is support services and ways to deal with provided through home visits, with the focus problems. Various awareness raising action parental capacities and psycho-education vities focused on psychosocial issues are sessions, aiming to increase wellbeing at organised, such as street drama and spread- family level. ing information through brochures and Tobetter tailor psychosocial services for the posters. On special days, such as World target group, and assess family situations in Refugee Day and World Suicide Prevention the context of third country resettlement, Day, humanitarian and refugee organis- TPO Nepal conducted a vulnerability and ations arrange thematic awareness raising dependency assessment by visiting families activities, such as essay competitions for at their homes. This assessment has led students or street drama. People are invited to recommendations to the humanitarian to write down their memories, feelings and agencies that speci¢cally address the needs ideas on a toran (Sanskrit word for ‘pass’, of vulnerable families, through regular visits which may refer to a sacred or honori¢c gate- and referrals when necessary. way, or a decorative hanging in Hinduism or Buddhism, such as prayer £ags). These What works and what can be improved? writings can be spread by the wind, acting Awareness raising Awareness raising activities both as a memorial, as well as an awareness are important in order to draw attention to raising tool. These activities are used to psychosocial problems as well as to available increase awareness of, for example, suicide

prevention, psychosocial support and ser- often o¡ers the quiet space required for vices of aidagencies. It may be, however, that people to freely discuss their issues. the most vulnerable people do not attend When there are internal family con£icts, such events. Therefore, visits to potentially family members may join in on a counselling vulnerable families are also important. session. In such a counselling session, atten- Additionally, TPO Nepal broadcasts a fort- tion is focused on mediation and psycho- nightly regional radio programme, in education including information on, for Nepali, addressing psychosocial issues, such example, alcoholism, suicide prevention as mental disorders, family problems, stress, and/or mental disorders. Additionally, relax- alcoholism, and suicide prevention. The ation exercises, to address anxiety or stress, programme targets refugees as well as the can also be included. host community. On average, people attend between ¢ve and Psycho-education Psycho-education on psycho- ten counselling sessions. While some may social issues and coping strategies can need more (specialised) support, in general, contribute to enabling people to di¡erentiate the counselling sessions provide the necess- between positive and negative coping ary knowledge and skills to cope di¡erently mechanisms, and help them ¢nd new ways with the challenges they face. It was found to cope. For instance, when people are when a person is depressed and has suicidal addicted to alcohol or drugs, psycho- thoughts because other family members education is one essential element, but have already resettled, combined with their severely addicted people will also bene¢t not knowing if and when they can resettle, from the specialised care of rehabilitation it may take a lot of e¡ort to motivate the centres. As many people may relapse, it is client to look at the situation from a di¡erent also important to continue with follow-up perspective. However, counselling and programmes and support, ¢nding ways for sharing experiences with others facing com- these refugees to give new meaning to their parable situations may be quite useful. lives. Family, CBOs and aid agencies can People who face multiple, complex problems all contribute to this process. often require a variety of support from Psychosocial counselling Psychosocial counsel- di¡erent caregivers, for example, in cases of ling can include individual, family or group severe mental disorders such as schizo- counselling. For many people, counselling phrenia or severe depression, medical sup- provides an opportunity to share their port5 is necessary. Referrals to psychiatrists experiences, feelings and problems in a con- and community mental health prescribers structive way. Especially when it concerns (MHP) (refugee sta¡ trained in recognising family issues, refugees perceive it as very mental health disorders, and providing helpful for a neutral person to listen and medication) can o¡er additional mental assist in the search for ways to deal with health care to these refugees. problems. However, o¡ering psychosocial Challenges to providing psychosocial counselling support can be challenging, as people fear Practical problems and daily stressors are their family matters may be discussed with often very challenging, not only for the others within the community. Sometimes refugees but also for the counsellors provid- counsellors are requested not to visit them ing support. Additionally, most psychosocial in their huts out of fear that people may talk counsellors and CPSWs are quite young, about it. Therefore, the o⁄ce in the camp often in their mid 20 s. While on the one

173 Copyright © War Trauma Foundation. Unauthorized reproduction of this article is prohibited. Psychosocial support for Bhutanese refugees in Nepal Intervention 2013, Volume 11, Number 2, Page 169 - 179

hand, dealing with complicated cases may interacting withyoung clients, as within such not only require input from a psychologist a large population, it remains a challenge or psychiatrist, but may also require some to reach all those in need of support. Another life experience, especially when clients are challenge is the fact that most refugee sta¡ much older. On the other hand, young members who have been trained will resettle psychosocial counsellors may also demon- at some point, so that experienced people strate a £exible, open-mind and ease in leave and new sta¡ have to be trained.

Case study: an example of a psychosocial intervention

Kunja is a 23 year old, female refugee. She is married, but has no children. Kunja had been abused by her husband and other family members, including both physical and mental forms of abuse. Her husband was unsupportive. She presented with complaints of anxiety, fear, restlessness, flashbacks, feelings of loneliness, suicidal ideation, and dizziness.When she could no longer bear her situation she sought help with apsychosocial counsellor.Kunja moved in with herparentsduringthetherapysessions, even though she is not legally divorced. Staying with her parents was good for Kunja and helped to reduce her symptoms. In the psychosocial counselling sessions, cognitive behaviour therapy was used (explained below) in order to offer her support to become stronger. For her, it was fortunate that her parents were the direct caregivers,asherhusband and in-laws were unwillingto help.Additionally,although herabusers were not arrested or removed, there was a legal process in progress. The first few sessions focused on allowing Kunja to identify her problems, while creating an atmosphere where she could feel comfortable to share them. She began to vent her problems and emotional difficulties, as well as the abuse experienced in the family.The counsellors frequently intervened with the family, especially with her husband. However, her husband continued to side with his family (especially with his parents) and, therefore, disregarded Kunja’sfeelings and the problems she wanted to share with him. He even ignored her when she tried to share good, or positive feelings with him. By the seventh session, Kunja had strengthened her level of confidence and her mood symptoms had drastically improved. She was given daily homework assignments, and taught to challenge intrusive thoughts, one at a time. By regularly challenging negative thoughts, she was able to feel stronger. Notesofthe dailyevents made in a diarywerehelpfulto observeher thoughts in different situations,and to then correct them. Muscle relaxation therapy was used to relax her mind and body, and improve coordination.Within each session, positive changes were observed, both in her daily activities, such as meeting people or sharing feelings and in her coping mechanisms. She is now more hopeful and motivated. In the course of the therapy,Kunja washappy to join English language class, attend thebeauty-parlour, and was also motivated to receive ‘alternative to violence’training sessions conducted in the camp. She learned to remain independent and be decisive to make her life meaningful.The intervention was dis- continued when there was a marked reduction in symptoms. In the end, Kunja declared herself happy and said;‘this is my new life, and I want to continue it’.

Suicide prevention and intervention Because psychosocial problems of children while of the high level of suicide attempts and contributing to their communication skills, those committed, UNHCR, Asian Medical self-esteem and skills for cooperating with Doctors Association (AMDA) Nepal and others. Childrenparticipate through playing TPO Nepal decided to design a suicide games, dancing, singing and drawing, which prevention and intervention protocol. This stimulate cooperation, interaction, and protocol aimed to: increase coordination sharing of feelings and ideas. One challenge and cooperation, reduce the amount of to address is that the children are from suicide attempts and those committed, and vulnerable family backgrounds where to give more clarity in terms of which agency problems related to substance disorders, should intervene, and at which stage. domestic violence and various other issues Sta¡s from both o⁄ces in Damak and are all quite prevalent. The CBI supervisor Kathmandu, as well as ¢eld based sta¡, were and facilitators, as well as counsellors, also consulted. Furthermore, community consul- arrange activities for parents, addressing tations were organised in order to guarantee issues like good parenting and commu- the views of the refugee community were nication, as well as providing psycho- also represented in the process.This last con- education on issues such as substance abuse sultation was very important, as front line and creating a safe place for children at workers from the refugee community are home. Schools, school counsellors and often the ¢rst ones expected to give support teachers are also involved in activities, and to victims and families, especially during take part in training on psychosocial nights and weekends when there are limited problems and support related to behavioural agency sta¡ present in camps. The protocol disorders, bullying, and the school as a has now been completed, its use will be protective place, among others. monitored and reviewed, and a suicide Women’s empowerment group (WEG) Group prevention group will be created.Their work interventions where people with the same will include commemorating World Suicide challenges can share their experiences and Prevention Day on 10 September at the ideas, can contribute to feelings of solidarity, camps, every year. Additionally, consultant increase self-con¢dence, and create changes psychiatrists who visit the camps once or in attitude and coping strategies. In the twice a month have agreed to involve coun- camps, there are many single women who sellors in their consultations with refugees have lost their husband through either death so that the counsellors can learn from these or divorce. The Bhutanese Refugee Women sessions about mental health issues, and Forum (BRWF) and TPO Nepal initiated cooperationbetween psychiatrists and coun- WEG classes with the aims of supporting sellors can be increased. Even with resource women to ¢nd new ways to cope with family constraints and the challenge to ¢nd time problems, share experiences and feelings, for these consultations, this cooperation and to increase self-esteem. There are also should contribute to increased linkage and classes for women a¡ected by domestic care related to mental health and psycho- violence. Some groups are running very social support. well, and the feedback from participants is Classroom Based Intervention (CBI) CBI is a very positive. Other groups lack continuity ¢ve week long structured group interven- due to the high level of absence of partici- tion, with the combined aims of reducing pants who are either too busy taking care

175 Copyright © War Trauma Foundation. Unauthorized reproduction of this article is prohibited. Psychosocial support for Bhutanese refugees in Nepal Intervention 2013, Volume 11, Number 2, Page 169 - 179

of their families, or are reluctant to share and/or psychosocial support, and refer them their feelings. Another challenge is that accordingly. The training resulted in a problems shared can sometimes be quite cooperation and referral system between severe or di⁄cult, andtherefore also challen- IOM andTPO Nepal. Similarly,TPO Nepal ging for counsellors to facilitate the sessions. provided training for the CMOs and MHPs Group harm reduction (GHR) GHR activities of the nongovernmental organisation have been introduced in order to address (NGO) Asian Medical Doctors Association problems related to substance disorders, like (AMDA). These interventions have also alcoholism. An assessment in two camps strengthened cooperation at camp level, showed that substance use rates were not between medical sta¡ members and psycho- alarming, but hazardous drinking was social counsellors. present. As a result, special care and aware- Another recommendation resulting fromthe ness campaigns were recommended (Luitel assessment related to lack of attention paid et al., 2010). Group harm reduction is an to psychosocial aspects of the cultural orien- approach where people who are facing the tation that refugees receive from IOM, prior same type of problems participate in groups, to their resettlement to third countries, and awareness is raised through psycho- about these respective countries. As it was education. Participants can share their found that some refugees commit, or experiences and write a contract with them- attempt, suicide after their arrival in their selves in which they can address their will new country, it is essential to prepare refu- to stop using alcohol. For some refugees this gees. This preparation should include what approach worked well. For psychosocial they can expect, which psychosocial issues counsellors, the challenge remains to stimu- they may face, and how to support each late people to participate in the sessions other in their new setting. IOM and TPO and to keep them involved. Nepal decided to jointly develop training modules on these issues, for both aid workers Capacity development and refugee representatives. Schinina' et al. (2011) found that attention to knowledge and skills on mental health and Conclusions and lessons learned psychosocial support was limited among TPO Nepal and partner organisations have most of the humanitarian agencies working sensitised refugees to psychosocial issues, with Bhutanese refugees in Nepal, andthere- contributed to capacity building of sta¡ fore recommended that the mhGAP Interven- and refugees, and provided counselling tion Guide (WHO, 2010) be used to address services to refugee and host communities. these gaps among the agencies. To achieve The resultant recommendations and lessons this, TPO Nepal provided training with learned follow below. the mhGAP Intervention Guide for the doctors and nurses of the International Continuous psychosocial services for refugees and Organisation for Migration (IOM) who hosting community perform medical screening of refugees, For the coming years, it is recommended to before they are resettled to third countries. continue the psychosocial services at camp As a result, medical sta¡ are now able to level and to create or link these to existing better identify those refugees who would psychosocial services for host communities bene¢t from a psychological assessment as well. This will ensure attention is given

to psychosocial support during, and after, the in this humanitarian programme. At camp reduction phase for humanitarian interven- level, meetings are already held but these tions for this group of refugees. need to be accompanied by joint capacity Those refugees remaining in Nepal can then development for sta¡ from di¡erent agencies also bene¢t from the shared psychosocial in order to increase cooperation and facilities. Continuation of care for remaining improve referral between agencies. refugees is also important, as the ones who stay behind are often the most vulnerable, such as the elderly and people with severe Follow-up illness or mental disorders. Involvement of It would be helpful to explore possible the host community can contribute to the linkages with psychosocial organisations in creation of a social care network for both the countries where refugees resettle, in communities. Developed psychosocial inter- order to develop a system of handing over ventions for the refugee community can cases and sharing experiences, as well as ideally be integrated and embedded in exist- psychosocial support. This is of particular ing care interventions and structures in the importance in terms of suicide prevention region, taking into account both culturally and strengthening the psychosocial situation acceptable and international standards for vulnerable refugees who might need ( Jordans & Sharma, 2004). support in the process of becoming new citizens and how to fully engage in their Strengthening of refugee community new country. Involving the refugee community, by either consulting them on needs and ideas or Acknowledgements training them as CPSWs, aids in strengthen- The authors would like to acknowledge UNHCR, ing self-esteem and improves psychosocial IOM, AMDA Nepal, LutheranWorld Federation, wellbeing within the community. When World Food Programme and Caritas for their preparing for the World Suicide Prevention cooperation and support in the facilitation of the Day, one of the CPSWs said; ‘‘we are so proud delivery of psychosocial services in the Bhutanese to organise this together.This will be our day.’’ refugee camps in Nepal. We also thank the local, international and refugee sta¡ of these organis- Vulnerable groups ations for their work and input. Vulnerable groups such as senior citizens, refugees with a disability, and single headed households needextra attention. Elderly refu- References gees had been through a lot, some of them Adelman, H. (2008). Protracted displacement in Asia: experienced horrible events in Bhutan then no place to call home. Hampshire: Ashgate. £ed to Nepal and spent decades in a refugee camp. Often, their children and grandchild- Hutt, M. (1996).Ethnic Nationalism, refugees and ren may want to resettle, whereas they would Bhutan. Journal of Refugee Studies, 9,397-420. rather go back to Bhutan or stay in Nepal. Inter-Agency Standing Committee (IASC) Enhance links and cooperation (2007). IASC Guidelines on Mental Health and It is important to enhance cooperation Psychosocial Support in Emergency Settings. between international and national NGOs Geneva: IASC.

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Jordans, MJD.& Sharma, B. (2004).Integrationof the Humanitarian Emergency Settings psychosocial counselling in care systems in Perceived Needs (HESPER) Scale. American Nepal. Intervention, 2,171-180. Journal of Public Health, 102, e55-e63.

Jordans, MJD., Komproe, IH., Tol, WA., Kohrt, Sharma, N. (2009). Bhutanese Refugee Situation: B., Luitel, NP., Macy, R. & de Jong, JTVM. An Assessment of Nepal-Bhutan Bilateralism, (2010). Evaluation of a School Based Psycho- Kathmandu School of Law, Bhaktapur, 2009, social Intervention in Nepal: a Randomized www.ksl.edu.np. ControlledTrial. Journal of Child Psychology and Psychiatry, 51, 818-826. Thomas, F., Roberts, B., Luitel, NP., Upadhaya, N. & Tol, W. (2011). Resilience of refugees dis- Loescher, G. & Milner, J.H. (2005). Protracted placed in the developing world: a qualitative refugeesituations:domesticand internationalsecurity analysis of strengths and struggles of urban implications. London: Routledge refugees in Nepal. Con£ict and Health, 5,20.

Luitel, N.P., Gyawali, N. & Jordans, M. (2010). TPONepal(2010),AnnualReport2010.Kathmandu, Final Report on Substance Abuse Assessment inTwo TPO Nepal. Bhutanese Refugee Camps, Kathmandu: TPO Nepal. World Health Organization (WHO (2010). mhGAPInterventionGuideforMental,Neurologoical Luitel, N.P., Karkai, K., Prasai, B. & Jordans, M. and Substance Use Disorders in Non-Specialized (2009). Psychosocial Issues of Bhutanese Refugees. HealthSettings. Geneva:World Health Organiz- Compilation of Findings of Qualitative Study. ation. Kathmandu: TPO Nepal. 1 Including, among others, the Camp Manage- Prasad Dahal, R. (2011). Psychosocial Protection ment Committee (CMC),the Bhutanese Refugees Strategies for Bhutanese Refugees in Nepal. Women Forum (BRWF), the Bhutanese Refugees Kathmandu, Nepal. Unpublished document Children Forum (BRCF) and the Youth Friendly (available from author upon request). Centres (YFC). 2 TPO Nepal developed a multi-level and Schinina' , G., Sharma, S., Gorbacheva, O. & multi-component care package, compatible Mishra, A.K. (2011). ‘Who am I?’, Assessment of with recommendations made by the Inter Agency Psychosocial Needs and Suicide Risk Factors Among Standing Committee Guidelines on Mental Health BhutaneseRefugeesinNepalandAfterThirdCountry and Psychosocial Support in Emergency Settings Resettlement’. Geneva/Damak: International (IASC, 2007). Organization for Migration, United Nations 3 Needs of the refugee community are re£ected High Commissioner for Refugees, Bureau of in vulnerability assessments and speci¢c studies, Population, Refugees and Migration. such as on the resilience of refugees in Nepal (Thomas et al., 2011). TPO Nepal participated Semrau, M., van Ommeren, M., Blagescu, M., in the study to develop the Humanitarian Emer- Griekspoor,A.,Howard,LM.,Jordans,M., gency Settings Perceived Needs (HESPER) Lempp, H., Marini, A., Pedersen, J., Pilotte, Scale, for which information was collected I., Slade, M. & Thornicroft, G. (2012). The among the Bhutanese refugees (Semrau et al., Development and Psychometric Properties of 2012).

4 This is provided by the Asian Medical Doctors (2006^2007). Based on the results of a research Association (AMDA), Nepal. study (Jordans et al., 2010), the CBI package was 5 The Classroom Based Intervention (CBI) was further adapted and implemented with refugee adapted, and implemented, in14districts in Nepal children in the camps from 2009.

Relinde Rei¡ers, MA Cultural Anthropology, MATransnational Communication & Global Media, MA Humanitarian Action, Project CoordinatorWarTrauma Foundation, the Netherlands, (former) psychosocial advisor toTranscultural Psychosocial Organisation (TPO) Nepal. Email: r.rei¡[email protected] Ram Prasad Dahal, MA (English),currently Social Protection Specialist in UNDP/Government of Nepal Ministry of Local Development under Human Development and Social Protection Pilot project, Nepal. Suraj Koirala, MA population studies, Executive Manager,TPONepal, Kathmandu, Nepal. Renee Gerritzen, certi¢ed mental health psychologist. Nawaraj Upadhaya, MA, MSc, HealthNetTPOAfghanistan, Kabul, Afghanistan. Nagendra P.Luitel, MA, Research Coordinator,TPONepal, Kathmandu, Nepal. Shaligram Bhattarai,MA,MPhil (ClinicalPsychology),MA,MPhil (English),Project Coordinator, TPONepal, Field O⁄ce, Damak, Nepal. MarkJ.D. Jordans, PhD,Head of Research, HealthNetTPO & Honorary Senior Lecturer, London School of Hygiene andTropical Medicine, London, UK.