Humanitarian crises affect people’s mental and psychosocial wellbeing and disrupt the social fabric of communities and families. Over the last decade, attention to mental health and psychosocial support (MHPSS) in the humanitarian sector has increased, and standards for MHPSS interventions have been developed.+Inter-Agency Standing Committee (IASC), IASC Guidelines on Mental Health and Psychosocial Support in Emergency Settings, 2007. Researchers in this field have identified ten fundamental questions the humanitarian sector needs to focus on.+W. A. Tol et al., ‘Research Priorities for Mental Health and Psychosocial Support in Humanitarian Settings’ PLoS medicine 8(9), 2011. One concerns the effectiveness of family-based interventions in preventing mental disorders and protecting and promoting psychosocial wellbeing. This article reflects on a community support programme – the ‘Multi-Family Approach (MFA) through Community Based Rehabilitation (CBR)’ – in the West Bank, involving NGOs, community-based organisations and universities from the occupied Palestinian territory, the Netherlands and the United Kingdom.
There is a significant unmet need for mental health and psycho-social support in the West Bank.+S. de val D’espaux et al., ‘Strengthening Mental Health Care in the Health System in the Occupied Palestinian Territory’, Intervention 9, 2011. People with physical and mental handicaps are especially vulnerable in this situation of political, social and economic hardship. For mothers of children with a disability it is very challenging to care for these children, their families and themselves given the lack of services, socio-economic constraints, stigma and social isolation.
The MFA brings together mothers of children with a mental or physical disability to share experiences and learn from each other. The project was developed and implemented by the War Trauma Foundation and the Institute for Community and Public Health (ICPH) at Birzeit University in the West Bank, in collaboration with the Community Based Rehabilitation (CBR) programme, the Dutch national centre for psychotrauma Foundation Centrum ‘45 and Sioo, an inter-university centre for change management. It is based on Multi-Family Therapy, developed by the Marlborough Family Service and Education Unit in London.+E. Asen and M. Scholz, Multifamily Therapy: Concepts and Techniques (London: Routledge, 2010). The intervention is grounded on the premise that people in similar situations can provide each other with company, stress relief and practical problem-solving ideas; one MFA group, for instance, brings together women with autistic children from three West Bank villages, where they receive support from other mothers whose children suffer from the same condition.+S. Mitwalli and Y. Rabaia, ‘Piloting the Multi-family Approach in Community-based Rehabilitation: An Observational and Interview-based Study’, The Lancet 390, 2017. Sessions involve enjoyment and relaxation for mothers, alongside serious conversations around shared personal, family and community experiences. A group facilitator is present, but since the MFA is a peer-support programme they are there merely to guide the process, not deliver content. The women themselves decide what topics they wish to discuss. Group facilitators are CBR employees trained by their peers, who have themselves been trained by an expert in MFA, and ICPH. Many have a background in social work. After a one-year pilot, an MFA manual drawing on experience in the West Bank has been developed, in collaboration with the MFA facilitators. The manual is illustrated with exercises that can be implemented during sessions, including getting to know one other, relationship-building and fun.+War Trauma Foundation, The Multi-Family Approach in Humanitarian Settings, 2015. Since CBR is community-based and the MFA facilitators are CBR staff who run the groups as part of their work, it is likely that the programme will continue to exist even if international actors take on a more distant role.
There are currently around 40 groups, each consisting of around ten women. Sessions are usually held once a month, or every two months. Members report that the caring and trusting environment within the groups has enabled them to exchange experiences and talk freely about their children’s problems. The women also report reduced stigma and feeling less stress. Not only do mothers in the MFA groups feel better, but their families also notice positive changes at home; one of the mothers said ‘my husband says I’m less irritable and more patient’. Group members are also more confident, and are now lobbying at the Ministry of Education for better educational opportunities for their children. This empowerment is expanding to other domains as well, for example involving local authorities such as the municipality.
Facilitators occasionally need to explain the purpose of the group meetings to potential participants, and how they can benefit from them. Women may have negative attitudes towards receiving mental health support because of the stigma that surrounds mental health issues in the West Bank. They may also have unrealistic expectations about the impact of MFA on their lives, and some may join a group in search of support beyond mental health, such as income-generating initiatives or medicine for their disabled children.
The CBR has struggled to provide adequate support to very vulnerable groups, such as mothers with severely disabled children who need continuous care. This is a difficult group to cater to because the children need to be looked after while the mothers are attending the MFA group. In some groups youth volunteers are available to do this, but these children typically need special care, which the volunteers are not able to provide without specific training.
One question we’ve grappled with is whether to work only with mothers, with fathers as well or with mixed groups. In the end we chose to work with mothers exclusively, in part because most fathers work some distance from their home, making it difficult for them to participate in training sessions, and the women are expected to share their experience and learning from the support groups at home. However, fathers could be involved at a later stage.
A frequently asked question from field partners is how best to support the mental wellbeing of their employees and volunteers. Working with people in distress can be extremely stressful, and compassion fatigue and burn-out among mental health care workers can be a risk. One useful tool for monitoring the health status of staff is the Professional Quality of Life Scale (ProQol).+B. H. Stamm, The Concise ProQOL Manual, 2nd ed. (http://www.proqol.org/uploads/ProQOL_Concise_2ndEd_12-2010.pdf). This 30-item questionnaire explores the positive and negative aspects of helping distressed people. Peer consultation is also provided for MFA facilitators, so that they can share with each other the difficulties they are facing and reflect on themselves and their way of working, exchange information and knowledge with other MFA facilitators and get practical advice and learn new techniques for dealing with their own feelings and emotions.
This overview shows the importance of engaging MHPSS in humanitarian action on a community level. Although MHPSS is a relatively new element in the humanitarian field, an increasing number of organisations and programmes now include MHPSS. The discipline is quickly evolving, and research and sharing best practices on how to strengthen both health systems and communities are essential. There is significant strength in joint research and programming, involving universities, NGOs and governments, adding to each other’s experiences and knowledge. Within these processes, attention to the wellbeing of communities and humanitarian workers is vital. Experience from our joint interventions and research programmes highlights the importance of different perspectives, and strengthening knowledge, skills and mental and psychosocial wellbeing worldwide.
Relinde Reiffers is a senior project coordinator at the War Trauma Foundation in the Netherlands, where Kimberly Stam is a junior researcher. Suzan Mitwalli is a project coordinator and researcher at the ICPH. The authors would like to thank everyone who has worked with us, making progress in the field of MHPSS possible.