If you are consumed by worries, can you focus on your work? If you are overpowered by anger because of what they did to you, can you manage the challenges of life in a refugee camp? If you are too sad to get out of bed in the morning, do you have the energy to breastfeed? If you do not sleep because of nightmares, can you be an attentive caregiver? Such questions challenge us to look beyond the material and physical needs in humanitarian settings, and raise the importance of the mental health and psychosocial wellbeing of people affected by humanitarian emergencies. Research has shown that mental health and psychosocial wellbeing are important factors in successful programming in economic development and livelihoods, child development and education, protection and human rights, nutrition and, ultimately, individual and collective recovery from conflict and disaster. With regard to health, this can be summed up under the slogan ‘no health without mental health’.+M. Prince, ‘No Health without Mental Health’, Lancet 370(9590), 2007; World Health Organisation, ‘Mental Health: Facing the Challenges, Building Solutions’, in Report from the WHO European Ministerial Conference, WHO Regional Office for Europe, 2005. In this paper we describe opportunities for integrating mental health and psychosocial programming into humanitarian response, and discuss strategies for overcoming the challenges associated with introducing multi-sectoral interventions into existing systems.
The Inter-Agency Standing Committee (IASC) provides specific recommendations for integrating mental health and psychosocial support (MHPSS) programmes into humani-tarian response sectors including food security and nutrition, education, shelter and site planning and water and sanitation.+Inter-Agency Standing Committee, IASC Guidelines on Mental Health and Psychosocial Support in Emergency Settings (Geneva: IASC, 2007).[/footnote These recommendations are supported by a growing recognition of the relationship between mental health and psychosocial wellbeing on the one hand, and on the other the objectives of humanitarian programming, such as safety and meeting basic needs. For example, gender-based violence is a well-known factor in worse mental health outcomes. The reverse is also true: women who are experiencing negative mental health consequences of violence are more vulnerable to suffering further violence. Intimate partner violence and mental health, as well as poverty and mental health, appear to form vicious circles. Such vicious circles may best be broken through integrated programming.
Points of integration for MHPSS into humanitarian assistance
Physical and mental health
The integration of mental and physical healthcare has been a goal of many health systems in both low- and high-resource settings. Given the well-documented relationship between mental and physical health, the health system may be an obvious starting point for integration. Currently, mental health services are often provided in parallel to physical health services and focus almost exclusively on treatment. Integrating screening and effective brief interventions into primary care may serve to identify people in need of referral to specialised services, prevent mental disorder for people displaying sub-threshold symptoms, increase awareness about mental health and the consequences of displacement and disaster, reduce the stigma commonly associated with seeking mental health services by delivering care in neutral settings and improve outcomes for a variety of chronic and infectious diseases.
A critical priority in humanitarian assistance is meeting basic needs. The stressors associated with not meeting one’s basic needs have a significant impact on wellbeing, which can further impair nutritional status, hygiene and safety. Equitable delivery of food and non-food items that enables autonomy, dignity and safety can increase the effectiveness of humanitarian assistance. Recommendations for integrating social and psychological considerations into activities focused on the provision of basic needs may include respecting cultural practices surrounding food and shelter, consideration of pre-existing socio-political tensions between groups, protecting the privacy of beneficiaries, avoiding discrimination, planning distribution and community development activities in such a way that they do not create environments that enable violence (e.g. crowded distribution lines with limited supply and inequitable distribution) and designing policies that avoid amplifying power imbalances and perpetuating marginalisation. With regard to nutrition, research shows that the promotion of exclusive breastfeeding may greatly benefit from attention to maternal mental health.
Education programmes commonly aim to promote the social, cognitive and emotional development of children and adolescents affected by humanitarian crises, and provide a source of stability in situations of displacement or disruption. The degree to which education incorporates MHPSS principles may vary, from programmes developed to provide a safe environment for learning to those that intentionally strengthen coping strategies, disseminate information related to survival and protection and train teachers to identify mental health and psychosocial challenges in their students and manage mild behavioural problems. A recent call to action for global child mental health identified the education sector as a critical entry point for coordinated efforts to promote wellbeing in children in low-resource settings.
The objectives of MHPSS and protection programmes are clearly aligned. For example, in many humanitarian settings interpersonal violence, particularly gender-based violence, is a particularly salient protection and MHPSS concern for women. In an effort to explore the feasibility of an integrated protection and MHPSS intervention to address these related challenges for Congolese refugee survivors of intimate partner violence in Tanzania, we designed an eight-session intervention building upon an evidence-based mental health treatment, Cognitive Processing Therapy,[footnote]Cognitive Processing Therapy (CPT) is an evidence-based manualised group or individual intervention. CPT aims to help participants recognise and modify thinking patterns related to experiencing severe trauma that are associated with worse mental health outcomes (for example, blaming yourself for having experienced violence, or thinking that you are worthless). and incorporated safety planning and advocacy components to be delivered by protection staff in a refugee camp. We conducted qualitative research to inform the development and implementation of an integrated intervention, and subsequently conducted a randomised pilot trial to explore the feasibility, relevance and acceptability of such a programme.
Designing the intervention required community engagement to identify local priorities and explanatory models describing the relationship between violence and mental health. The main mental health problems affecting female survivors of intimate partner violence were stress, sadness and fear. Counselling was recommended to address these problems in Nyarugusu refugee camp. The intervention began with an individual session with a locally trained facilitator, who conducted a danger assessment and assisted the woman in developing a safety plan to mitigate risks and consequences of partner violence. The remaining seven sessions were delivered by a pair of trained facilitators to a group of 10–12 women.
Sessions two to six consisted of Cognitive Processing Therapy components, including an introduction to the relationship between thoughts and feelings, relaxation training, exploring stuck points and thinking errors, changing thoughts and feelings and other self-care strategies. In the final session, women reviewed their safety plans as a group and discussed empowerment, coping and support methods.
Through extensive piloting and a qualitative process evaluation we determined that, with dedicated efforts to promote ownership and buy-in among partners across sectors, it is possible to integrate MHPSS services into protection activities in humanitarian settings. Despite the well-recognised relationship between violence and mental health, as well as guidance from both the MHPSS and protection community to integrate these activities, we do not know of rigorous evaluations of integrated protection and MHPSS interventions for survivors of genderbased violence in humanitarian settings. The aforementioned example in Tanzania+Funding for the study was provided by Elrha’s Research for Health in Humanitarian Crises (R2HC), supported by the UK Department for International Development and the Wellcome Trust. may serve as a model for designing, piloting, implementing and evaluating a dedicated integrated protection and MHPSS intervention.+W. A. Tol et al., ‘An Integrated Intervention to Reduce Intimate Partner Violence and Psychological Distress with Refugees in Low-resource Settings: Study Protocol for the Nguvu Cluster Randomized Trial’, BMC Psychiatry 17(1), 2017; ‘Nguvu: Empowering Survivors of Intimate Partner Violence’, r2hc Project Blog, elrha, 2016; ‘First Pilot of Nguvu: What Did We Learn?’, r2hc Project Blog, elrha, 2017; ‘Developing Integrated Psychosocial Interventions in Refugee Settings’, r2hc Project Blog, elrha, 2017.
Restoring livelihoods, empowerment and early recovery
The capacity to participate in and contribute to rebuilding one’s community is directly related to mental health and psychosocial wellbeing. One of the fundamental challenges that can stifle progress towards recovery is poverty. Poverty alleviation interventions, specifically cash transfer and asset promotion programmes, have been found to improve mental health and, similarly, mental health interventions have been shown to reduce poverty in low- and middle-income countries.+C. Lund et al., ‘Poverty and Mental Disorders: Breaking the Cycle in Lowincome and Middle-income Countries’, The Lancet 378(9801), 2011. What is lacking from the evidence is the effect of combined poverty reduction and MHPSS interventions. Poverty alleviation efforts represent one mechanism by which humanitarian activities could be sustained throughout the early recovery period, and the integration of MHPSS services may be one way of magnifying that effect.
Overcoming implementation challenges
Despite efforts to strengthen humanitarian coordination, including through the cluster system, connecting work across (and for that matter within) sectors is still challenging. Based on our experience in Nyarugusu refugee camp, we present some of the implementation challenges for integration, along with possible strategies for overcoming them.
The first challenge lies in aligning programme priorities across sectors. This challenge is reinforced by the way humanitarian response is structured, with sector-specific implementation partners and mandates, funding streams that are allocated within sectors and human resources with focused capacity. Overcoming coordination and resource challenges requires buy-in from all sectors involved. Engaging partners and building ownership of integrated projects that span sectorsis imperative to their successful adoption and sustainability. Dedicating sufficient time in the early phases of integrated interventions to present a rationale for introducing multisectoral strategies, harmonising theories of change and generating enthusiasm around the programme will strengthen stakeholder commitment and resource investment. In our experience, training protection staff in MHPSS service provision was possible, but it was difficult to protect their time for training and the delivery of services that did not fall within their mandate. Implementing the integrated mental health and protection intervention we introduced earlier required that we negotiate how staff time would be allocated and compensated given their new dual role as protection and MHPSS providers.
Obtaining funding to support multi-sectoral interventions is another challenge that may call for creative solutions. A shift in how funds are earmarked may require stronger evidence surrounding the effectiveness of integrated interventions in improving humanitarian assistance. Strengthening the evidence base for integrated programming is challenging because of the complex design of integrated interventions. Experimental, randomised-controlled trials are considered the strongest evaluation design, but they are resource-intensive. In addition, investing in controlled trials (for example, in checking implementation quality and ongoing supervision) may not be feasible in many humanitarian contexts. Non-experimental designs and implementation-focused studies may serve as an alternative to experimental studies and, with an adequate design, may also provide indications of intervention effects. Comparing integrated interventions to sector-specific interventions delivered in parallel and/ or usual care requires large sample sizes and long follow-up periods, which further increases resource requirements. Additional efforts and flexibility from donors, practitioners and evaluators are needed to bridge this gap in knowledge and strengthen the evidence on integrated MHPSS strategies in humanitarian assistance.
Making progress towards integration of MHPSS in humanitarian response
Conflict, disaster or displacement can disrupt access to shelter, economic opportunities, social support, food and clean water, health services and education. A unifying theme of that disruption is that it may threaten one’s psychological and social wellbeing due to fear and uncertainty, adverse and potentially traumatic experiences and a sense of loss across these domains. In order to bolster humanitarian response, a coordinated, multi-sectoral approach that integrates activities to address these threats to wellbeing is needed. Through the strategies outlined above, MHPSS services can be integrated into each of these sectors in a complementary, as opposed to competing, manner. To date, there are few
examples documenting the implementation of integrated efforts; however, guidelines exist for a range of MHPSS activities specific to humanitarian settings that are accessible to non-specialised providers.+IASC Guidelines on Mental Health and Psychosocial Support in Emergency Settings; WHO and UN High Commissioner for Refugees, mhGAP Humanitarian Intervention Guide (mhGAP-HIG): Clinical Management of Mental, Neurological and Substance Use Conditions in Humanitarian Emergencies (Geneva: WHO, 2015). Efforts to develop and evaluate potentially scalable interventions (i.e., interventions requiring fewer resources than traditional evidence-based mental health interventions) that may be prime candidates for integration into multi-sectoral programmes are also under way.+‘SH+ Trial Completed: What Are the Next Steps?’, elrha Project Blog, elrha, 2018. At the very least, programmes should consider the social and psychological implications of what, how, when and to whom aid is delivered, and design activities in a way that promotes wellbeing for all beneficiaries in humanitarian settings.
M. Claire Greene is a doctoral candidate in the Department of Mental Health at Johns Hopkins Bloomberg School of Public Health and an NIDA Drug Dependence Epidemiology Training Fellow. Samuel Likindikoki is a lecturer and psychiatrist in the Department of Psychiatry and Mental Health at Muhimbili University of Health and Allied Sciences, where Jessie Mbwambo is a Senior Researcher and psychiatrist. Wietse Tol is an Associate Professor in the Department of Mental Health at Johns Hopkins Bloomberg School of Public Health and Program Director at the Peter C. Alderman Foundation.