The psychological and mental health needs of refugees and people in emergency situations have, in the past, been overlooked. Now recognised as important, a range of ‘psychosocial’ activities has developed, but are these interventions appropriate and effective? Willem van de Put, from HealthNet TPO, reports on the impact of these activities and whether it is time to revise interventions in this area.
Aid workers, under attack in Chechnya and Somalia at the end of the 1980’s and early 1990’s, changed from sacred humanitarians into legitimate targets for armed groups pursuing broad political aims. This brought home to policy makers in the humanitarian world, in a very direct and brutal way, the impact of traumatic experience. The issue of how to deal with traumatised humanitarian staff helps us to understand the original specific emphasis on psychotrauma as an urgent need in emergencies.
Undoubtedly, humanitarian crises have detrimental effects on mental health and wellbeing. Enormous populations are affected. In 2009, more than 119 million people were affected by natural disasters, and 36 armed conflicts took place in 26 different countries. Research showed an increase in psychological distress, social problems, common mental disorders (depression, anxiety, including Post-traumatic Stress Disorder [PTSD]) and severe mental disorders (e.g. psychotic disorders). Epidemiological studies identified population rates of depression and PTSD ranging between 15 percent – 20 percent.
Since that time, mental health and psychosocial care have rapidly appeared on the agenda of emergency responses. In 1992, soon after the start of the siege of Sarajevo, it was difficult to convince parties to respond to the cry for assistance coming from the mental health department of the largest hospital in the city. Only six years later, hundreds of agencies prepared a psychosocial response to the Kosovo crises. This fast development was not without problems. Methodological questions arose. Should western concepts be used? Should traditional ways of healing be considered? Questions also abounded about the ethics of a psychological intervention model to respond to ongoing conflicts and injustice, (see: Summerfield1) and about political interpretations of the hidden agenda of the international humanitarian world (‘pathologising populations and colonising minds’).2
A mixture of medical and social views in psychosocial work
Psychosocial problems appear easier to describe than to confront in practice. The trauma perspective includes a problematic focus on the individual instead of on society and communities. Since the beginning of psychosocial interventions, demands have been made for a conceptual shift away from individualistic approaches towards working with the entire community. But it is very difficult for health agencies to realise that shift.3 For non-medical agencies, the psychological aspects of the challenge tend to disappear quickly behind routine community programme assumptions.
Relative priority of mental health issues in emergencies
It seems wise to separate clinical medical work from interventions that focus on relations between people at community level. In the medical realm, early guidelines to responding in emergencies included referral options to psychiatric care, but psychiatric services did not exist in most of the emergency settings. It is self-evident that health systems should include psychiatry, but this poses a very different set of questions for programme developers. Developing basic psychiatry in primary care requires a health systems approach which is not suitable in an emergency response, and it also requires a vision of what primary psychiatry should include and not include. Prevalence of severe mental disorders is usually thought to be around two to three percent of the population, and may increase in the aftermath of disaster to around three to four percent (IASC 2007). Many programmes include elements of psychiatry without restrictions, including treating people with severe mental disorders in the context of an emergency programme.
The missing evidence base for interventions
In non-medical settings, the threat of wasting scarce resources on severe mental disorders led to a shift in the nature of psychosocial interventions. The interventions moved from identifying psychiatric cases to providing psychosocial care, psychoeducation, enhancing the coping mechanisms of survivors and encouraging community-based self-help groups. In this new field, no one had clear views of an evidence base, and while thousands of flowers blossomed, few of these flowers were documented and measured. Psychosocial work came close to being a banner for almost anything that was proposed to donors.
All of these challenges only stress the importance of finding sustainable ways to respond to established needs. The experience of the last twenty years helps in taking the next steps.
Psychosocial care in emergencies
In the field of psychosocial care in emergencies, people still struggle to coordinate efforts and work from an evidence base. In a yet to be published study, Tol and others point out that while two recent sets of international guidelines4 indicate an increasing consensus in recommendations for psychosocial support interventions, divisions remain among both researchers and practitioners on the key issues.5
These issues include:
- A continuing concentration on PTSD as a central research and intervention focus.6
- A distinction between normal psychological distress and mental disorders in situations of adversity.
- The extent to which interventions should aim to target the consequences of past traumatic experiences or ongoing structural and situational stressors in the recovery environment, for example family separation, poverty and inability to meet basic needs, human rights violations and political instability.
- The balance of community-wide preventive and promotional interventions, as opposed to the treatment of mental disorders in humanitarian settings.7
It was also painful to realise that during the latest emergencies (Haiti, Japan) the Inter-Agency Standing Committee (IASC) Guidelines did not help to coordinate planning.
Hope on the horizon
The debate on evidence and agency policies is likely to continue for some time. Meanwhile, we are learning. The importance of social networks and the use of local resources for help have been established beyond doubt. The ‘conservation of resources theory’ (COR) helps to identify why psychosocial interventions need to start from an understanding of the community, and how they are more effective when targeted at the community rather than at its individual members.8 The COR is a comprehensive theory of stress, based on the central view that people strive to obtain, build and protect that which they value (resources), and that psychological stress occurs when these resources are lost. It also works the other way around: putting the emphasis on the context helps to identify how lost resources can actually be restored or replaced. It puts the control where it belongs: with communities.
A worldwide panel of experts on the study and treatment of people exposed to disaster and mass violence has reached consensus on intervention principles that should be used to guide and inform intervention and prevention efforts at the early to mid–term stages. This promotes safety and calm, and a sense of self– and community efficacy, connectedness and hope. These elements are surely necessary for the continuing development of effective interventions to help people in emergencies face their despair. At some point, someone will perhaps take the trouble to uncover the history of these attempts in a more rigorous way.
1 See on Kosovo programmes: Psychosocial notebook: Volume 1, 2000: Psychosocial and Trauma Response in war-torn societies: the case of Kosovo. IOM 2000. For a more political assessment of the same situation: Vanessa Pupavac: Pathologizing populations and colonizing minds: International Psychosocial Programs in Kosovo. In: Alternatives 27 (2002) 489-511
2 See e.g. Miller KE, Rasmussen A (2010) War exposure, daily stressors, and mental health in conflict and post-conflict settings: bridging the divide between trauma-focused and psychosocial frameworks. Social Science & Medicine 70: 7-16; and Honwana AM (1997) Healing for peace: traditional healers and post-war reconstruction in Southern Mozambique. Peace and Conflict: Journal of Peace Psychology 3: 293-305.
3 These are the Inter-Agency Standing Committee [IASC] (2007) IASC Guidelines on Mental Health and Psychosocial Support in Emergency Settings. Geneva: IASC, and the Sphere Project (2011) Humanitarian Charter and Minimum Standards in Disaster Response – 2011 Edition. Geneva, Switzerland: The Sphere Project
4 Wietse A Tol., Patel, V., Tomlinson, M., Baingana, F., Galappatti, A., Panter-Brick, C., Silove, D., Sondorp, E., Wessells, M., van Ommeren, M.: Running title: mental health and psychosocial research priorities in humanitarian settings. In press.
5 van Ommeren M, Saxena S, Saraceno B (2005) Mental and social health during and after acute emergencies: emerging consensus? Bulletin of the World Health Organization 83: 71-75; discussion 75-76.
6 Tol WA, Barbui C, Galappatti A, Silove D, Betancourt TS, et al. (Under Review) Mental health and psychosocial support in humanitarian settings: linking practice and research
7 Hobfoll, S.E. (1988). The ecology of stress. Washington, DC: Hemisphere. (1989). Conservation of resources: A new attempt at conceptualizing stress. American Psychologist, 44(3), 513-524. (2001). The influence of culture, community, and the nested-self in the stress process: Advancing conservation of resources theory. Applied Psychology: An International Review, 50(3), 337-421.