His mother had tied him to the fragile pillar holding up their rickety shelter in the refugee camp. He was 20, acutely manic and disinhibited. The camp bordered areas of active conflict; wandering could have fatal consequences. I accompanied the health worker and lay counsellor who visited the shelter to engage him and his family in treatment. His mother had restrained him to stop him from leaving. Should we call it stigma? Or was it best intentions in impossible circumstances, trampling on his rights and dignity? I came to think it was the latter — especially when she brought him for follow-up once his symptoms settled. He remarked “she doesn’t have to tie me up now” with no apparent anger toward his mother.

I have worked as a psychiatrist in the UK, New Zealand, Australia and India, as well as on short assignments in humanitarian contexts. Since 2017, as a field worker with Médecins Sans Frontières (Doctors Without Borders), I have supported conflict-affected populations in South Sudan, Ethiopia, Yemen, and among Rohingya refugees and other displaced communities from Myanmar.

Typically lasting three to six months, these assignments focus on building capacity within local healthcare teams to integrate psychiatric care into primary care services. Providing quality mental healthcare for individuals in communities is entirely feasible in humanitarian settings. Communities surviving conflict and displacement demonstrate extraordinary grit and resilience. Working alongside them is enriching, even as it involves witnessing immense suffering.

A 30-year-old man was once brought to the clinic by neighbours with acute psychosis. With medication and psychosocial support, he improved and returned to his village. After missing a scheduled review, he reappeared weeks later, having walked two days through muddy bush along the Nile as his mental state deteriorated. The trained health worker de-escalated him and restarted treatment. The system, however rudimentary, had worked.

Modern mental health systems often feel complex and layered. In humanitarian contexts, one is confronted by the absence of systems altogether, with an urgent need to create something functional. It makes me wonder whether we could design our systems more simply. A model that is elegant, fit for purpose, built on straightforward processes yet capable of delivering effective, high-quality care feels like a kind of holy grail.

Healthcare workers in these settings are often clinical officers, nurses, and occasionally medical doctors, many with limited formal exposure to psychiatry. The WHO’s mh GAP programme is an excellent tool for training health workers in low and middle-income settings (indeed, high-income countries may lose out by not using it more widely).

Adapting training to context is crucial. I have learned to move away from “teaching” conventional psychiatry in a purely didactic sense. Instead, I try to adopt a socio-anthropological lens to understand how mental distress is experienced and conceptualised locally. Working with local terminology and mapping it thoughtfully onto psychiatric concepts is far more effective than attempting literal translations from English. Co-creating training materials with community health workers has made me a better supervisor. I can only hope they gained from me a fraction of what I learnt from them. In communities devastated by death and displacement, long-standing relational supports and collective problem-solving traditions can fragment or disappear. 

Individuals experiencing mental illness may be left without the informal psychosocial scaffolding that sustains recovery. Providing psychiatric care in such contexts requires cultural humility and historical awareness — something Aboriginal and Torres Strait Islander, Māori, and Pasifika communities understand deeply.

Humanitarian work has made me a better psychiatrist. For those seeking challenge, perspective and professional growth, I would recommend it wholeheartedly.