Several ICRC departments are involved in addressing the multi-faceted needs of the families of missing persons. The specific mental health and psychosocial support (MHPSS) component is carried out in collaboration with local partner NGOs and selected relatives of missing persons trained to work as accompaniers. All accompaniers are female in order to avoid sending males into female-headed households. They are trained and supported by a multidisciplinary team to understand and address the wide range of needs of the families of missing persons and to provide a bridge to local services. The MHPSS intervention consists of a six-month cycle during which various activities are carried out (Table 1).
Table 1. The six-month cycle of MHPSS activities
The MHPSS component of the ICRC’s Accompaniment Programme in Sri Lanka draws heavily on ambiguous loss theory and the notion that uncertainty regarding the fate and whereabouts of a loved one is extremely distressing. The literature on ambiguous loss purports that the emotional difficulties and manifestations of common mental health problems like anxiety and depression are not to be seen as psychiatric disorders, but rather as a social and relational problem.[i] Thus, the therapeutic goal is to reinvest in emotional attachment, garner social support and build resilience to cope with the ambiguity. The intervention guidelines for working with ambiguous loss[ii] were integrated as culturally and contextually adapted themes into eight support-group sessions offered to relatives of missing persons. In addition to conducting group sessions, the ICRC-trained accompaniers also carried out individual home visits and referred families with particular needs (financial, legal, medical or other) to local service-providers under the joint supervision of a coordinator from the partner NGO and an ICRC psychologist.
The accompaniers were selected from the area in which the target families lived and, in most cases, they were themselves relatives of missing persons. The minimum criteria for selection included: high school education, emotional stability, mobility (i.e. able to travel around), female gender (to avoid sending males to female-headed households) and motivated to support other relatives of missing persons.
In order to build the capacities of the accompaniers using adult participatory methods, the initial five-day training session included basic support skills (empathic listening and interviewing techniques), how to conduct assessments (i.e. how to use the self-reported questionnaires to assess multi-faceted needs, and the self-reported psychological distress questionnaire), resource mapping (to understand all the resources linked to the different needs of families), understanding and managing stress, and basic techniques of problem-solving-based counselling. Immediately after the initial training session, the accompaniers went to the field to put these skills into practice, under the supervision of the coordinators and the ICRC psychologist. This was followed by a second four-day training session on how to conduct support groups. The training was designed in such a way that the theme-centred group discussions were experienced by the accompaniers first, which allowed them to get first-hand experience of the content of the sessions.
The peer groups consist of eight sessions designed as follows: Session I deals with introductions, setting group norms including confidentiality, constructing a group identity with a group name, and understanding and clarifying the objectives of the support groups. Session II introduces the concept of family system and focuses on helping family members revisit and value the different roles and functions that they have in their lives, while being aware of the roles and functions of other family members. The session aims to facilitate a re-evaluation of the relative’s identity, and thus paves the way for reconstruction. Session III introduces the concept of ambiguous loss and its effect on our mind, our body, our behaviour and our relationships. The session aims to recognize the source of the problems derived from having a missing relative within the social and political context and to normalize the reactions that relatives experience. The session also includes a discussion of the various coping mechanisms that each relative uses within his or her social and cultural context.
Session IV shifts focus away from the relative towards revisiting the memory of the missing person. Each participant shares a personal positive remembrance with the group. At the end of the session, the group members are encouraged to bring something in memory of the missing person (such as an object, food, song, etc.) to the following session to share with the group if they wish to do so. In sessions V and VI, group members are encouraged to discuss ways of paying tribute to their missing relatives as a group. Group members brainstorm ideas and come up with a commemoration event. The commemoration event seeks to allow group members to carry out a meaningful ritual or tribute and gain recognition for their missing relatives, and for themselves. For the actual commemoration event, families invite other community members, including village and/or religious leaders, as well as representatives of authorities where appropriate.
Session VII offers a reflection on the social support network of the group members. This session aims to help them realize that they are not alone and that there are people who are there to help them. A personal map is drawn as a tool for this exercise. Finally, session VIII is a joint evaluation of the group process. The group members are also encouraged to discuss whether they want to continue to meet on their own, and how they would see this through.