Epidemiology and Psychiatric Sciences (2015), 24, 495–497. doi:10.1017/S204579601500058X
© Cambridge University Press 2015
C O M M E N TA R Y T O SPECIAL ARTICLE
A reflection on the strengths and limits of a public health approach to mental health in humanitarian settings
Received 14 June 2015; Accepted 25 June 2015; First published online 9 September 2015 Key words: Emergency psychiatry, mental health, risk factors, social support.
Commentary on: Tol WA, Purgato M, Bass JK, Galappatti A, Eaton W (2015). Mental health and psychosocial support in humanitarian settings: a public mental health perspective. Epidemiology and Psychiatric Sciences. (doi:10.1017/S2045796015000827)
mental health work and psychosocial work. Each of these important suggestions is considered in turn.
The mental health impact of large scale humanitarian crises is now well established and visible both in situations of armed conflict and so called natural disasters. Yet, supports for the mental health of crisis-affected people have been limited in numerous ways. Overall, mental health work has been reactive and has not given equal priority to prevention. This is true even in low- and middle-income contexts that have ongoing or recurrent crises and few psychiatrists or clinical psychologists. Also, work on mental health in humanitarian settings has tended to be non-holistic and medicalised. Often there is extensive focus on posttraumatic stress disorder (PTSD), when other widespread mental health issues such as depression receive little attention. Outside psychologists or psychiatrists may set up specialised treatment centres for trauma, but such centres tend to be unsustainable and fragment health care. Poor sustainability also occurs when interventions imposed from outside neither build upon local resources nor adapt the supports to the socio-historic context. Adding to these challenges is the limited evidence base regarding the effectiveness of various mental health supports in emergency settings (Tol et al. 2011; Betancourt et al. 2013). In this context, the paper by Wietse Tol and his distinguished colleagues is a valuable stimulus for fresh thinking. It calls for a public mental health approach and a revised terminology that focuses on mental health and enables a more integrated, conceptually unified approach and reduces the divisions between
A public health approach could do much to help address the problems outlined above and enable crisis-affected people’s well-being. Well known for their ability to provide support on a wide scale, public health approaches move us beyond case-based approaches to a focus on well-being at the population level. A public health approach also places strong emphasis on prevention. Consistent with social ecological models (Betancourt et al. 2013), a public health approach strengthens preventive and promotive factors that help to promote wellbeing and avoid the development of mental disorders. Unlike deficits orientations, this approach promotes resilience and guides practitioners to work systematically on both preventing risk factors and strengthening preventive and promotive factors (Wessells, 2015). Further, a public health approach could enable a more comprehensive, coordinated approach to mental health in humanitarian crises. A public health approach could strengthen health systems that include mental health supports. Unlike narrow conceptions, public health approaches invite attention to diverse problems, systemic interconnections between them and ways of changing social environments that support people’s well-being. Since public health work is guided by systematic evidence, public health approaches could also help to boost the accountability of mental health work. For these and other reasons, I enthusiastically support taking a public health approach to mental health in humanitarian crises.
A public health approach
Terminology, integration and coordination Address for correspondence: M. Wessells, Columbia University, Program on Forced Migration and Health, New York, USA. (Email: [email protected])
Tol et al. also made valuable points about the problems associated with current terminology regarding ‘mental
496
M. Wessells
health and psychosocial support’ (MHPSS). As they correctly point out, these terms have often been defined in different ways, and there is no integrated, consensus framework on the causation and relations between mental health problems and psychosocial problems. They note that the IASC Guidelines on Mental Health and Psychosocial Support in Emergency Settings helped to create a more holistic framework for action by showing the complementarity of work at different levels of the intervention pyramid. Yet at field level, problems of coordination frequently arise (IASC, 2014). In emergencies, the Health Cluster coordinates work on mental health, whereas the Child Protection Sub-Cluster of the Protection Cluster coordinates work on holistic psychosocial supports. It can be challenging to get the two coordinating groups to coordinate with each other. Also, in many humanitarian crises, one sees the organisation of numerous community-based programs for psychosocial support, but with few effective channels for the referral and treatment of people in need of specialised support. To help address these problems, Tol et al. suggest a public mental health approach, with ‘mental health’ defined broadly to include well-being rather than the absence of mental disorders alone. Although this refocusing on mental health is inviting, it raises numerous complex questions. For example, would this approach risk unravelling the broad agreement and comprehensive intervention framework developed by the IASC Guidelines? The agreement that all four levels of the intervention pyramid are essential in every emergency context was not a simple political compromise that gave each group a piece of the turf. Indeed, this agreement reflected the conceptual awakening to a more holistic comprehensive approach that grew out of the extensive dialogue and co-learning that occurred during the development of the Guidelines. The Guidelines deliberately used the composite term ‘mental health and psychosocial support’ to ‘describe any type of local or outside support that aims to protect or promote psychosocial well-being and/or prevent or treat mental disorder’ (IASC, 2007, p. 1). The logic was that many aid workers saw the two elements – mental health and psychosocial support, respectively – as interrelated, overlapping and as complementary yet as different approaches. This remains true at present for most workers in the MHPSS sector. In this context, attempts to subsume all the work on MHPSS under the rubric ‘mental health’ may be disenfranchising for psychosocial workers, many of whom take a relational, contextualist approach and question the individualistic and universalised approach of much work on mental health. Questions also arise in regard to vested power and interests that shape how ‘mental health’ is understood and used. Will medically oriented health actors likely take a holistic approach to mental health? Or will
they likely reproduce the medicalised approaches that their institutions are charged with implementing? Following the political violence in Kenya in late 2008, for example, the Ministry of Health coordinated work on mental health and focused mostly on mental disorders such as PTSD, with little attention given to other layers of the intervention pyramid. Instead of moving towards a broader and better integrated approach, one might see a narrower approach and possibly an even greater schism between MHPSS work than is evident in the field at present. An important question is how to train mental health workers in ways that enable them to address needs for specialised treatment as well as the full array of psychosocial and protection issues related to family separation, recruitment into armed forces or armed groups, trafficking, gender-based violence, forced early marriage, or discrimination, among many others? Psychosocial work and the protective work that constitutes its preventive arm cover an expansive terrain that requires its own forms of specialised expertise. Typically, this work is done by social workers, psychologists and other specialists who have a strong protection background and community orientation. At the least, movement towards exclusive use of the term ‘mental health’ would require an extensive overhaul of training for professionals who respond to humanitarian crises. One wonders whether there is sufficient agreement among current mental health professionals and psychosocial workers about what should be taught as part of a more integrated curriculum. At the time the IASC Guidelines were developed, consensus on such issues did not exist. On the donor side, could the exclusive use of the term ‘mental health’ cause significant confusion and undermine the funding needed for the work that is conducted currently under the rubric ‘psychosocial support.’ Augmenting this concern is the author’s observation that trauma sells, that is, it is easier to obtain funding for trauma healing programs than the ‘fuzzier’ psychosocial programs that cover diverse issues. Also, governments are currently favouring research on neurological impacts of trauma, thereby favouring the ‘bio’ aspect of the more holistic bio-psychosocial approach. These questions are not intended to undermine an integrated terminology and approach to mental health but call attention to the need for much further consensus building, testing of different approaches and attention to the strategic aspects of reshaping a field. For now, it seems best to favour a public health approach to MHPSS and to pursue the dialogue that Tol et al. wisely recommend. M. Wessells Columbia University, Program on Forced Migration and Health, New York, USA.
A reflection on the strengths and limits of a public health approach to mental health in humanitarian settings References Betancourt T, Meyers-Ohki SE, Charrow AP, Tol WE (2013). Interventions for children affected by war: an ecological perspective on psychosocial support and mental health care. Harvard Review of Psychiatry 21, 70–90. Inter-Agency Standing Committee (2007). The IASC Guidelines on Mental Health and Psychosocial Support in Emergency Settings. Author: Geneva. Inter-Agency Standing Committee (2014). Review of the Implementation of the IASG Guidelines on Mental Health and
497
Psychosocial Support in Emergency Settings: How are we Doing? IASC Reference Group on Mental Health and Psychosocial Support: Geneva. Tol WA, Barbui C, Galappatti A, Silove D, Betancourt TS, Souza R, Golaz A, van Ommeren M (2011). Mental health and psychosocial support in humanitarian settings: linking practice and research. Lancet 378, 1581–1591. Wessells MG (2015). Commentary: a social environment approach to promotive and protective practice in childhood resilience: reflections on Ungar (2014). Journal of Child Psychology and Psychiatry 56, 18–20.
© Cambridge University Press 2015
C O M M E N TA R Y T O SPECIAL ARTICLE
A reflection on the strengths and limits of a public health approach to mental health in humanitarian settings
Received 14 June 2015; Accepted 25 June 2015; First published online 9 September 2015 Key words: Emergency psychiatry, mental health, risk factors, social support.
Commentary on: Tol WA, Purgato M, Bass JK, Galappatti A, Eaton W (2015). Mental health and psychosocial support in humanitarian settings: a public mental health perspective. Epidemiology and Psychiatric Sciences. (doi:10.1017/S2045796015000827)
mental health work and psychosocial work. Each of these important suggestions is considered in turn.
The mental health impact of large scale humanitarian crises is now well established and visible both in situations of armed conflict and so called natural disasters. Yet, supports for the mental health of crisis-affected people have been limited in numerous ways. Overall, mental health work has been reactive and has not given equal priority to prevention. This is true even in low- and middle-income contexts that have ongoing or recurrent crises and few psychiatrists or clinical psychologists. Also, work on mental health in humanitarian settings has tended to be non-holistic and medicalised. Often there is extensive focus on posttraumatic stress disorder (PTSD), when other widespread mental health issues such as depression receive little attention. Outside psychologists or psychiatrists may set up specialised treatment centres for trauma, but such centres tend to be unsustainable and fragment health care. Poor sustainability also occurs when interventions imposed from outside neither build upon local resources nor adapt the supports to the socio-historic context. Adding to these challenges is the limited evidence base regarding the effectiveness of various mental health supports in emergency settings (Tol et al. 2011; Betancourt et al. 2013). In this context, the paper by Wietse Tol and his distinguished colleagues is a valuable stimulus for fresh thinking. It calls for a public mental health approach and a revised terminology that focuses on mental health and enables a more integrated, conceptually unified approach and reduces the divisions between
A public health approach could do much to help address the problems outlined above and enable crisis-affected people’s well-being. Well known for their ability to provide support on a wide scale, public health approaches move us beyond case-based approaches to a focus on well-being at the population level. A public health approach also places strong emphasis on prevention. Consistent with social ecological models (Betancourt et al. 2013), a public health approach strengthens preventive and promotive factors that help to promote wellbeing and avoid the development of mental disorders. Unlike deficits orientations, this approach promotes resilience and guides practitioners to work systematically on both preventing risk factors and strengthening preventive and promotive factors (Wessells, 2015). Further, a public health approach could enable a more comprehensive, coordinated approach to mental health in humanitarian crises. A public health approach could strengthen health systems that include mental health supports. Unlike narrow conceptions, public health approaches invite attention to diverse problems, systemic interconnections between them and ways of changing social environments that support people’s well-being. Since public health work is guided by systematic evidence, public health approaches could also help to boost the accountability of mental health work. For these and other reasons, I enthusiastically support taking a public health approach to mental health in humanitarian crises.
A public health approach
Terminology, integration and coordination Address for correspondence: M. Wessells, Columbia University, Program on Forced Migration and Health, New York, USA. (Email: [email protected])
Tol et al. also made valuable points about the problems associated with current terminology regarding ‘mental
496
M. Wessells
health and psychosocial support’ (MHPSS). As they correctly point out, these terms have often been defined in different ways, and there is no integrated, consensus framework on the causation and relations between mental health problems and psychosocial problems. They note that the IASC Guidelines on Mental Health and Psychosocial Support in Emergency Settings helped to create a more holistic framework for action by showing the complementarity of work at different levels of the intervention pyramid. Yet at field level, problems of coordination frequently arise (IASC, 2014). In emergencies, the Health Cluster coordinates work on mental health, whereas the Child Protection Sub-Cluster of the Protection Cluster coordinates work on holistic psychosocial supports. It can be challenging to get the two coordinating groups to coordinate with each other. Also, in many humanitarian crises, one sees the organisation of numerous community-based programs for psychosocial support, but with few effective channels for the referral and treatment of people in need of specialised support. To help address these problems, Tol et al. suggest a public mental health approach, with ‘mental health’ defined broadly to include well-being rather than the absence of mental disorders alone. Although this refocusing on mental health is inviting, it raises numerous complex questions. For example, would this approach risk unravelling the broad agreement and comprehensive intervention framework developed by the IASC Guidelines? The agreement that all four levels of the intervention pyramid are essential in every emergency context was not a simple political compromise that gave each group a piece of the turf. Indeed, this agreement reflected the conceptual awakening to a more holistic comprehensive approach that grew out of the extensive dialogue and co-learning that occurred during the development of the Guidelines. The Guidelines deliberately used the composite term ‘mental health and psychosocial support’ to ‘describe any type of local or outside support that aims to protect or promote psychosocial well-being and/or prevent or treat mental disorder’ (IASC, 2007, p. 1). The logic was that many aid workers saw the two elements – mental health and psychosocial support, respectively – as interrelated, overlapping and as complementary yet as different approaches. This remains true at present for most workers in the MHPSS sector. In this context, attempts to subsume all the work on MHPSS under the rubric ‘mental health’ may be disenfranchising for psychosocial workers, many of whom take a relational, contextualist approach and question the individualistic and universalised approach of much work on mental health. Questions also arise in regard to vested power and interests that shape how ‘mental health’ is understood and used. Will medically oriented health actors likely take a holistic approach to mental health? Or will
they likely reproduce the medicalised approaches that their institutions are charged with implementing? Following the political violence in Kenya in late 2008, for example, the Ministry of Health coordinated work on mental health and focused mostly on mental disorders such as PTSD, with little attention given to other layers of the intervention pyramid. Instead of moving towards a broader and better integrated approach, one might see a narrower approach and possibly an even greater schism between MHPSS work than is evident in the field at present. An important question is how to train mental health workers in ways that enable them to address needs for specialised treatment as well as the full array of psychosocial and protection issues related to family separation, recruitment into armed forces or armed groups, trafficking, gender-based violence, forced early marriage, or discrimination, among many others? Psychosocial work and the protective work that constitutes its preventive arm cover an expansive terrain that requires its own forms of specialised expertise. Typically, this work is done by social workers, psychologists and other specialists who have a strong protection background and community orientation. At the least, movement towards exclusive use of the term ‘mental health’ would require an extensive overhaul of training for professionals who respond to humanitarian crises. One wonders whether there is sufficient agreement among current mental health professionals and psychosocial workers about what should be taught as part of a more integrated curriculum. At the time the IASC Guidelines were developed, consensus on such issues did not exist. On the donor side, could the exclusive use of the term ‘mental health’ cause significant confusion and undermine the funding needed for the work that is conducted currently under the rubric ‘psychosocial support.’ Augmenting this concern is the author’s observation that trauma sells, that is, it is easier to obtain funding for trauma healing programs than the ‘fuzzier’ psychosocial programs that cover diverse issues. Also, governments are currently favouring research on neurological impacts of trauma, thereby favouring the ‘bio’ aspect of the more holistic bio-psychosocial approach. These questions are not intended to undermine an integrated terminology and approach to mental health but call attention to the need for much further consensus building, testing of different approaches and attention to the strategic aspects of reshaping a field. For now, it seems best to favour a public health approach to MHPSS and to pursue the dialogue that Tol et al. wisely recommend. M. Wessells Columbia University, Program on Forced Migration and Health, New York, USA.
A reflection on the strengths and limits of a public health approach to mental health in humanitarian settings References Betancourt T, Meyers-Ohki SE, Charrow AP, Tol WE (2013). Interventions for children affected by war: an ecological perspective on psychosocial support and mental health care. Harvard Review of Psychiatry 21, 70–90. Inter-Agency Standing Committee (2007). The IASC Guidelines on Mental Health and Psychosocial Support in Emergency Settings. Author: Geneva. Inter-Agency Standing Committee (2014). Review of the Implementation of the IASG Guidelines on Mental Health and
497
Psychosocial Support in Emergency Settings: How are we Doing? IASC Reference Group on Mental Health and Psychosocial Support: Geneva. Tol WA, Barbui C, Galappatti A, Silove D, Betancourt TS, Souza R, Golaz A, van Ommeren M (2011). Mental health and psychosocial support in humanitarian settings: linking practice and research. Lancet 378, 1581–1591. Wessells MG (2015). Commentary: a social environment approach to promotive and protective practice in childhood resilience: reflections on Ungar (2014). Journal of Child Psychology and Psychiatry 56, 18–20.
