Rohingya children in a UNICEF child-friendly space at Batukhali refugee camp in Bangladesh draw pictures of what they witnessed in Burma. Rohingya children in a UNICEF child-friendly space at Batukhali refugee camp in Bangladesh draw pictures of what they witnessed in Burma. Photo credit: © Anna Dubuis/DFID
Scalable psychological interventions for people affected by adversity
by Alison Schafer, Melissa Harper-Shehadeh, Kenneth Carswell, Edith van’t Hof, Jennifer Hall, Aiysha Malik, Teresa Au and Mark van Ommeren July 2018

There is a need to improve mental health outcomes in humanitarian settings. This includes strengthening community, family and other psychosocial support mechanisms, as well as improving access to psychological interventions. This paper provides a rationale for developing scalable psychological interventions and describes the World Health Organisation (WHO)’s work to encourage training of nonspecialist mental health care workers to deliver evidence-based psychological interventions.

With the emergence of several potentially scalable psychological interventions, attention should be paid to ensuring the quality of the care provided. This includes adapting interventions to the local culture and context and ensuring that non-specialist staff are trained and clinically supervised to safely and effectively deliver the intervention, while taking a careful, considered approach to scaling up. Field experiences and the strategies of successful psychological intervention programmes need to be shared to continue improving access and quality.

Mental health in crises

Globally, an estimated one in four people will experience a mental disorder at some point in their lives, but less than 20% will receive or have access to evidence-based treatment. Unsurprisingly, this disparity between needs and access is most pronounced in low-resource settings, and in humanitarian emergencies, where people’s mental health and psychosocial support (MHPSS) needs are increased. The Inter-Agency Standing Committee (IASC) Guidelines for MHPSS in emergency settings sets out agreed ways to provide MHPSS during humanitarian responses, and the right to the highest possible psychological and social wellbeing is affirmed in a range of humanitarian standards and initiatives, including the Sphere standards, the Central Emergency Response Fund (CERF), the Child Protection Minimum Standards and the IASC Guidelines for Integrating Gender-Based Violence Interventions in Humanitarian Action.

In 2015, the WHO and the UN High Commissioner for Refugees (UNHCR) published the mental health Global Action Programme’s Humanitarian Intervention Guide (mhGAP-HIG). The mhGAP-HIG is a clinical guide for the assessment and management of mental, neurological and substance use disorders in humanitarian health-care settings. In line with the forthcoming Sphere standard on mental health, programmes are encouraged to train staff as non-specialist mental health care workers (i.e. staff without specialised licences for mental health care) to deliver brief, evidence-based psychological interventions, such as cognitive behavioural therapy and interpersonal therapy. Use of a non-specialist mental health care workforce acknowledges that not every country, and especially not lower-resourced ones, has enough mental health specialists to reach and treat the number of people requiring care.

Evidence-based psychological interventions commonly used in high-resource settings can be effective in low-resource contexts, including when they are delivered by trained and supervised non-specialists. These interventions have proved helpful in the treatment of common mental health problems, such as depression, anxiety and traumatic and chronic stress, as well as other difficulties, such as harmful alcohol use. Cultural and contextual adaptations can increase the effectiveness of psychological interventions, and make them more accessible to people affected by crises. Treatments are best delivered in local languages, using recognisable terminology and case examples, and implemented in ways that do not exacerbate stigma or exclusion. Humanitarian settings demand psychological interventions that are as brief and as low-cost as possible, and which optimise limited human resources.

Scaling up

In recent years, WHO has committed to disseminating a range of easily adaptable and potentially scalable psychological interventions. While there is no hard-and-fast definition of ‘scalable’, interventions can be described as being scalable when they are able to reach more people at lower cost. The premise of psychological interventions promoted by WHO is that they are evidence-based (i.e. tested in randomised controlled trials), relatively brief, deliverable by a nonspecialist workforce, culturally and contextually adaptable, affordable, feasible in a range of contexts, potentially incorporate technology (e.g. online or pre-recorded self-help), publicly available and cost-effective.

WHO’s psychological interventions (see Box 1) are empirically supported and specifically designed for a non-specialist mental health care workforce. The interventions use simple core techniques that are as generic as possible, to enable easier adaptation and scalability. They also use simplified (non-diagnostic) approaches to determine if an individual needs the intervention. This means that interventions may address multiple mental health problems without needing to be specific about a mental disorder or diagnosis. Through gradual field use and experience, these interventions have shown potential for scale-up in different cultures, languages, systems, age groups and populations affected by adversity, whether in humanitarian contexts or elsewhere.

It may be tempting to roll out en masse what the evidence has shown to be effective. However, the scaling up of psychological interventions in any context poses particular challenges and risks. If done badly, interventions could harm prospective clients, the non-specialist mental health care workforce delivering the interventions and wider health systems. For example, mass scale-up without adequate systems, management, supervision or monitoring could lead to a poorly trained or clinically unsupervised workforce. Inappropriate implementation could see clients lose confidence in mental health services, increase stigma and discourage people from seeking help.

The effectiveness of a range of psychological interventions in humanitarian settings has been established. However, monitoring, evaluation and further research on implementation is needed, particularly when implementation is happening at scale. The core competencies of non-specialist mental health care providers also need to be determined across the different interventions and quality standards for programme design. Even so, there is now a strong rationale and sufficient evidence for humanitarian actors to include psychological interventions as part of their broader MHPSS programmes. Based on field experience and learning to date, taking a considered approach to scaling up psychological interventions would include:

  • Carefully examining the training needs of nonspecialist providers of psychological interventions, as well as those who train and supervise them.
  • Exploring approaches to ensure that psychological interventions are delivered as intended (sometimes referred to as ‘fidelity’), such as assessing the competencies  of non-specialists, using technology to minimise human error and project monitoring.
  • Advocating as non-negotiable the need for regular and skilled clinical supervision of non specialist mental health care providers, for the protection of both clients and helpers.
  • Encouraging programme designers to consider the potential burden of adding psychological interventions to the workload of non-specialist workers.
  • Working with existing community and government structures to ensure capacity development of local services.
  • Monitoring and evaluating the effectiveness – or potential harm – of psychological interventions, where such data is shared for ongoing inter-agency/global learning.
  • Allowing for the adjustment of programme implementation approaches, such as meeting growing demands for remote training (e.g. in conflict settings) and remote assistance (e.g. online programs).
  • Making resources available in order to adapt psychological interventions to account for contextual and cultural differences.

Like all humanitarian action, MHPSS response is a growing and evolving area. With interventions such as Problem Management Plus (PM+), evaluated in Pakistan with support from Elhra’s Research for Health in Humanitarian Crises Programme (R2HC), the desire and need to scale up are both pressing. However, care is essential to ensure that reaching more people does not mean reaching them in a less effective way. Scalable psychological interventions are being developed as an outcome of technical inputs, field-testing and scientific rigour. The next step is testing approaches to scaling up, and exploring the training needs of intervention providers to ensure the sustained quality of psychological support in humanitarian settings.

Alison Schafer, Melissa Harper-Shehadeh, Kenneth Carswell, Edith van’t Hof, Jennifer Hall, Aiysha Malik, Teresa Au and Mark van Ommeren are employed as technical staff or consultants with WHO’s Department of Mental Health and Substance Abuse.

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