���Some arrive and can�۪t sleep at all. Others arrive and immediately fall asleep for days on end,� says Pina Deiana, shouting from the front seat of a car clearly no stranger to the unforgiving roads of Sicily.
We�۪re heading to a refugee support centre deep in the rugged countryside, where Deiana has her first appointment of the day. While her colleagues at M̩decins Sans Fronti̬res (MSF) treat arrivals for everything from severe burns to injuries from violence, it is at these centres that Deiana deals with the less visible scars of the migrants�۪ journeys. She is one of only two MSF psychologists stationed on the island, and so over-stretched that our interview can only be squeezed in during a bumpy car ride.
Deiana�۪s work starts at the shore, in the first-aid reception centres nestled among the coastal rocks. The demand for psychological support has been high: this year MSF introduced ���psychological first aid� for victims of particularly traumatic sea crossings. Pozzallo, the nearest port, has received 8,000 refugees since January.
But for Deiana�۪s patients, this symbolic moment of arrival in Europe is so often the beginning of another long journey ��� that of psychological recovery. Much of this process happens in the place we visit today, an elegant country house now doubling up as one of the 16 ���exceptional� support centres on the island that Deiana spends her days zig-zagging between.
Refugee support centre in Sicily.
A country house doubling up as a refugee support centre in Sicily. Photograph: Holly Young
���When we arrive here we are out of our mind. We have taken so much suffering,� says Thierno Mouctar Barry, a former patient of Deiana�۪s who has now been at the centre for six months. ���We need psychologists like Pina to bring us back to the land ��_ back to reality.�
He lifts up his shirt to show the bite marks on his left arm ��� crescent shaped reminders of the 28 September 2009, an evening of severe police brutality in his native Guinea that sparked the beginning of his migration journey: Senegal, Mauritania, and then to ���another type of hell� ��� Libya.
���Before, I could not tell my story without crying. If I didn�۪t get that support I would probably be a different person,� says Barry.
Barry is just one of the hundreds of patients Deiana has treated this year. Most are male, between 19 and 30 years old, from Nigeria, Mali, Gambia and Senegal. ���One man was convinced he was still in the desert,� says Deiana, recalling a recent case of acute psychosis. ���He was drinking the water in the bowls for the dogs and eating leaves from the trees. He had frequent flashbacks where he thought he was being beaten by his traffickers again. He could hear traffickers telling him if he didn�۪t drink urine they would kill him. He told us he couldn�۪t lie down because when he did he could feel dead bodies on top of him.�
Another patient was recently referred to her with symptoms that resembled epilepsy. ���Her eyes would roll back into her head and her arms would go completely rigid ��� but it wasn�۪t really epilepsy, it was a psychological crisis ��_ It started when she was captured with 400 people in the desert in Sudan during her journey here. The fear was still very strong.�
The psychological and social stresses often experienced by refugees during migration can double the prevalence of severe disorders (psychosis, severe depression and disabling anxiety), and increase the figures of mild to moderate mental disorders from 10% to 15-20%, according to the World Health Organisation (pdf). Indeed Deiana says the number of cases in Sicily so far has been significantly more than they expected.
���But this does not mean these people are psychologically weak,� Deiana points out. Rather, she thinks, the figures are testimony to the cumulative impact of extraordinarily difficult experiences. ���Remember most people we meet have travelled for one year or more before landing in Sicily. So one year of danger, of dangerous situations ��_ with smugglers, with men in the desert, with combat situations in Libya.�
The stressful wait during the months after arrival is often when trauma takes shape. ���The past comes back, the present is difficult, and the future is uncertain,� says Deiana. People sometimes arrive in good mental health and become increasingly depressed as the months wear on.
Pina Deiana in Sicily
MSF psychologist Pina Deiana speaks to former patient Thierno Mouctar Barry in the garden of the refugee support centre. Photograph: Holly Young
The consequences of failing to provide sufficient psychological support to those that need it are well established, according to Richard Stott, clinical psychologist and specialist in anxiety disorders and trauma. ���There is a risk of long-term mental health conditions developing, including chronic post traumatic stress disorder, depression and risk of suicide,� he says. ���Untreated mental health conditions can be detrimental not only to the wellbeing of the individual, but also compromise physical health, parental functioning and the wellbeing of children and other family members.�
Despite this, mental health support is often neglected. ���In the current refugee crisis, with tens of thousands of desperate and exhausted refugees attempting to reach safe havens in Europe, mental health and psychosocial wellbeing is somewhat overlooked amid all the needs that are vying for attention,� says Pieter Ventevogel, senior mental health officer at UN refugee agency UNHCR.
Guglielmo Schinina, head of mental health at the International Organisation of Migration, is familiar with the argument that in the current crisis, other needs such as shelter should be prioritised. ���But I think European countries are more ready than we think ��_ I think there is capacity to deal with this,� says Schinina. ���The problem is that this capacity is not activated.�
It is in the months after arrival that 'the past comes back, the present is difficult, and the future is uncertain'
It is not only psychologists that can provide support, says Ventevogel, and it shouldn�۪t be limited to those with clinical mental disorders: ���Perhaps the most important thing to do is to treat refugees with respect and dignity, preserving and strengthening their autonomy and self-efficacy. It is critical that all who are involved in the refugee response, from border guards or police officers to medical personnel, have been properly trained in assisting people who are in great distress. One does not need a degree in psychology to support the mental health of refugees.�
There is, of course, a risk of misdiagnosis, point out some officials; many behaviours refugees show are not necessarily signs of mental health problems but natural responses to their circumstances. And this issue is further complicated by a lack of translators and cultural mediators, says Chiara Montaldo, the MSF coordinator accompanying Deiana on her visit.
���Last year one Nigerian man was at the centre in Pozzallo and he was doing a voodoo ceremony, which was normal for him. The operator there, however, thought it was a kind of ���craziness�۪ and referred him to the psychiatric department. This unfortunately happens quite often.�
���One of the first questions I ask is, ���How do you treat this problem in your country?�۪� says Deiana. Many patients ask her for access to traditional healers.
Helping patients to find a way of anchoring themselves in their new situation is also important, though supporting refugees through grief can be a real challenge. ���I did not know what to do in Islamic culture when somebody dies and you don�۪t have the body,� Deiana says.
In the end she worked with the local church in the cemetery in Pozzallo to try to mark graves for those lost. Many however remain nameless. As we prepare to leave, a staff member points to a traditional Malian house built by a recent resident ��� ���an important symbolic piece of home�.
���These people are stronger than us,� reflects Deiana on the drive back to Pozzallo. Her job takes her to dark places ��� nightmares, flashbacks, profound grief and loss ��� but it is a story of human resilience she wants me to leave with.
Helping to reestablish refugees�۪ trust in humanity, something so often severed after their traumatic experiences, makes it ���a very beautiful job� she adds. ���It might be a drop in the sea but I can be useful to these people.�