Needs and caseload analysis, organisation according to the IASC pyramid and management of sensitive cases

Pyramid: level 1, basic services and security that respect dignity (shelter, water, care, information on missing persons, dignified burials); level 2, community and family supports (support groups, child-friendly spaces, mourning rituals); level 3, focused non-specialised supports (brief intervention by counsellors); level 4, specialised services (psychiatrist, psychologists). PFA is a humane, first-line response by non-specialists, not a treatment.

Needs: severe disorders: 3 to 4% of 85,000 = 2,550 to 3,400 people; mild to moderate disorders: 15 to 20% = 12,750 to 17,000.

Coverage: specialised: 15 + 48 + 95 = 158 cumulative referrals, i.e. 4.6 to 6.2%; focused: 410 people followed, i.e. 2.4 to 3.2%. Not everyone concerned will seek care, but the gap is considerable.

Trends: the fall in PFA and the rise in community groups are normal at three months. The rise in referrals and in the waiting list is the warning sign.

Patients seen in month 3: 31 + 95 − 74 = 52, i.e. the psychiatrist's capacity (12 × 4.33). Without change: + 43 per month, i.e. 74 + 3 × 43 = 203 people waiting in month 6.

Triage: the 40 cases of moderate distress (42% of referrals) belong at level 3. Specialised inflow: 55 for a capacity of 52: the list barely grows any more (+ 3 per month).

Training general practitioners with the WHO mhGAP Humanitarian Intervention Guide and supervision by the psychiatrist: epilepsy (6) and alcohol use (18) managed in primary care. Specialised inflow: 31; the list falls by 21 per month and is cleared in about 3.5 months (74 / 21).

Suicidal ideation: none of these 22 people should remain on a waiting list. Risk assessment within 24 to 48 hours by a psychologist or trained doctor, safety plan, close follow-up, priority access to the psychiatrist.

Counsellors: 410 + 40 = 450 people followed; 450 / 20 = 22.5, i.e. 23 counsellors (5 more), while 6 are exhausted: recruit and protect the team at the same time.

1. Single-session psychological debriefing: the IASC guidelines advise against single-session psychological debriefing, which has shown no benefit and can cause harm; making it mandatory violates autonomy. Alternative: PFA on request, information on normal reactions and on services, support groups.

2. Benzodiazepines: WHO recommendations (mhGAP) advise against benzodiazepines for acute stress symptoms, with a risk of dependence. Alternative: supportive care, sleep and stress management, individual clinical assessment.

3. Posted list: serious breach of confidentiality and stigmatisation. Alternative: confidential records, restricted access, consent.

4. Separate trauma centre: vertical and stigmatising approach, not sustainable. Alternative: integrate mental health into primary health care and existing community services, as the guidelines recommend.

Case A: alleged sexual abuse of a child by a member of our programme: this is a case of sexual exploitation and abuse (SEA) and a child protection case.

1. Immediate safety of the girl: is she in danger today? Listen without intrusive questions, following PFA principles (look, listen, link), without promising absolute secrecy, explaining to whom the information will be passed on.
2. Referral, with her assent and in her best interests, to child protection and gender-based violence case management: medical care (time limits for post-exposure prophylaxis and emergency contraception), psychosocial support.
3. Mandatory and confidential report to the organisation's PSEA focal point within 24 hours. The counsellor does not investigate: investigation is the responsibility of the designated unit.
4. The volunteer is removed from all contact with beneficiaries during the investigation.
5. Information limited to the strict minimum; support and supervision for the counsellor.

Case B: refusal to film a group session: confidentiality, risk of harm and consent impossible to guarantee for a group in distress. Alternative: interview with a team member, images of activities without identifiable faces, or testimony from a recovered person with written consent and the right to withdraw.

• Weekly small-group clinical supervision by the psychologists, plus monthly individual supervision.
• Caseload capped at 20 people per counsellor; recruitment of the 5 missing counsellors; distribution of complex cases.
• Staff care: leave granted and organised on a rotating basis, recovery time, confidential external support, attention to counsellors who were themselves affected by the earthquake.
• Indicators: (1) % of people followed who show an improvement in functioning between admission and the end of follow-up, measured with an adapted and locally validated tool; (2) time between referral and the first specialised consultation (target: 14 days at most, 48 hours for suicide risk).