There's medical first aid. And then there's psychological first aid: an eight-step approach to help people who've been through trauma. It's part of the mission of the Doctors Without Borders staff to help the tens of thousands fleeing the northern city of Palma, ravaged by civil unrest.

They come by foot, covering around 200 miles, and sometimes by boat or plane if they're being evacuated as armed militias kill men, women and children and chase others into the bush.

They are often reeling from what they've seen — helplessly watching as family and friends were publicly beheaded or shot and their homes burned to the ground. Many of those who escaped and made the trek to the city of Montepuez came across the bodies of others who had been killed or died from hunger or thirst. And then there was the underlying anxiety that they might be caught themselves.

It's actually not the lack of food or water that has put them in such a desperate state when they arrive, says Ampara Vilasmil, the mental health activity manager for a camp set up by MSF in Montepuez. She says they usually don't have any serious physical issues except for sores on their feet from so much walking. Rather, it's the emotional turmoil they have had to deal with — sometimes repeatedly.

"We see people that have fled from other parts of the district to Palma, and now from Palma to Montepuez, and they are constantly reliving this horrible situation," she says.

Psychological first aid is exactly that — a first (and often short-term) line of defense that will hopefully give people the strength they need to function and handle whatever is next. For Vilasmil and her colleagues, there may only be one chance to offer psychological support before the fleeing Mozambiquans move to another location.

The first-aid staff members have to be flexible and offer a variety of services to reach people of different ages and in their care for varying durations — including group interventions, recreational activities, support groups.

In an email interview with NPR, Vilasmil shared impressions of this daunting first-aid effort. The interview has been condensed and edited for clarity.

Why did you decide a mental health component was needed here?

People had to leave under extremely violent conditions. They saw their homes being burnt, family or friends killed, and sometimes, they received death threats. Now that they are here, they will have to rebuild not only a home but the very concept of who they are while they process all the losses they've had along the way.

So the reason to have the mental health component is to help alleviate their suffering and enhance their coping.

What's the physical and mental state of those who come to you for help?

When people start talking about their experience, they usually cry while they mention all they have lost. They are also very much concerned for the rest of their families. We see people having problems sleeping, either because they can't sleep or have nightmares with images of what they saw.

What are the biggest mental health issues?

We see a lot of anxiety, some people are even showing some post-traumatic stress responses such as being hyperalert, having flashbacks or nightmares. We also notice a feeling of hopelessness. There's a lot of grief related to losing family members but also their belongings, their houses, their routines.

What about the children?

For children, this situation can be hard to understand as they are beginning to figure out how the world works. Some children are not so playful or talkative or are showing aggressiveness toward others. We also have children being easily scared and not trusting others.

How long are people with you?

It depends. Some people we only see once, as they are not staying in the camps or in Montepuez. In these cases, we usually provide psychological first aid — a first moment response to help them recompose. The idea is to help them organize their thoughts and needs in order to make decisions. So it is more a matter of listening to them, helping them prioritize their needs, giving them information on services available and tips on how to take care of themselves also mentally.

While working with people who live in the camps, we have the possibility to do follow-up sessions: counseling and psychological support, where we discuss more in depth the concerns of the person or family.

How do you even begin to do therapy and follow up with this population?

The first thing we do is sensitize people regarding mental health, because this is a very new concept. They often think mental health services are just for people with mental disorders, and they don't know that these concerns they have, this sadness or sensation of hopelessness, can be treated, that they don't have to do it all alone and that there are professionals that can help them overcome this.

Once they reach the mental health services, they find themselves in a space where they can express themselves freely. This alone can give them a sense of relief, because they feel that they can unburden themselves, letting out what they've been keeping inside. Many times, they feel they have to be strong all the time, so when they can finally express themselves it feels like taking a weight off.

If we know we won't be able to do follow-ups we try to give them tools to deal with their reactions — self-care strategies and stress management, like relaxation techniques or steps for decision-making when they feel overwhelmed.

In order to achieve this, we don't only stay in the consultation rooms. We offer house visits as well. Especially if the person lives too far from the health center or from the tent where we are providing the services.

And you provide this help ... wearing masks?

We take all the [pandemic]preventive measures such as use of masks, hand-washing and social distancing. This affects the interaction we have with people as they don't see our full face. It takes time to build the trust. When we do house visits, we try to stay in open spaces.

Also, if one of our staff shows symptoms, we have to isolate them for 14 days, which means sometimes we have to postpone or reschedule activities.

What has surprised you during your work with this population?

Despite all of this they are still willing to move forward, to try to get better, to try to continue with their lives. People will greet you with a smile as you walk through the camps, they are very open to listen to you. One time I mentioned this to one of our staff that is from Mocimboa da Praia and he said, "Of course they will smile. They are from Mocimboa." Despite everything, they haven't lost their essence, and this says a lot about them.

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