EDITORIALS

Inter-agency agreement on mental health and psychosocial support in emergency settings

Inter-Agency Standing Committee Task Force on Mental Health and Psychosocial Support in Emergency Settingsª; Mark van Ommeren^I,1; Mike Wessells^II

^IDepartment of Mental Health and Substance Abuse, World Health Organization, 20 avenue Appia, 1211 Geneva 27, Switzerland
^IIInterAction, Christian Children’s Fund (CCF), Washington, DC, United States of America

Armed conflicts and natural disasters cause substantial psychological and social suffering to affected populations.^1–3

Despite a long history of disagreements,⁴ international agencies have now agreed on how to provide such support. The Inter-Agency Standing Committee (IASC), established in response to United Nations General Assembly Resolution 46/182, is a committee of executive heads of United Nations agencies, intergovernmental organizations, Red Cross and Red Crescent agencies and consortia of nongovernmental organizations responsible for global humanitarian policy. In 2005, the IASC established a task force to develop guidelines on mental health and psychosocial support in emergencies.

The guidelines⁵ use the term "mental health and psychosocial support" to describe any type of local or outside support that aims to protect or promote psychosocial well being or to prevent or treat mental disorders. Although "mental health" and "psychosocial support" are closely related and overlap, in the humanitarian world they reflect different approaches. Aid agencies working outside of the health sector have tended to speak of supporting psychosocial well being.^1,6 Health sector agencies have used the term mental health, yet historically also use "psychosocial rehabilitation" and "psychosocial treatment" to describe non-biological interventions for people with mental disorders.⁷ Exact definitions of these terms vary between and within aid organizations, disciplines and countries, and these variations fuel confusion.⁸ The guidelines’ reference to mental health and psychosocial support serves to unite a broad group of actors and communicates the need for complementary supports.

The guidelines outline minimum responses; that is, the first steps to occur in supporting mental health and psychosocial well being during an emergency. This definition matters because agencies often attempt to set up specialized programmes without checking whether more basic mental health and psychosocial supports are in place. The focus on minimum, intersectoral response helped task force members find agreement in an area of aid that still has a weak evidence base.⁹

The structure of these guidelines is consistent with the IASC documents on HIV/AIDS¹⁰ and on gender-based violence.¹¹ These three documents include a matrix, which describes actions for various sectors during different stages of emergencies, and a set of short action sheets that explain how to implement minimum responses during the acute phase of an emergency. The current guidelines describe 25 such minimum-response action sheets. These mostly focus on protection and social support, but also include attention to pre-existing or emergency-induced severe mental disorders,¹² acute trauma-induced distress and substance use. Each action sheet includes descriptions of key actions, sample process indicators, an example of good practice and references to resource materials.

The guidelines highlight the importance of mobilizing groups of disaster-affected people to organize their own supports and participate fully in the relief effort. In this respect, local people are not passive beneficiaries but actors who have assets and resources, and support is provided from within the community as well as by outsiders.

Possibly the most far-reaching innovation of the guidelines is its emphasis on multisectoral action. The concept underlying this approach is that the way any type of humanitarian response is provided has implications, beneficial or detrimental, for the mental health and psychosocial well being of the affected population. Effective or harmful supports may result from the ways in which aid is organized or delivered. For example, shelter assistance helps to meet basic survival needs, but it can also be a barrier to mental health depending on whether it is implemented without concern for massive overcrowding and absence of privacy, sources of great distress among displaced people. Similarly, water and sanitation can be organized in a manner that risks or supports protection of women and girls through the establishment of secure or insecure facilities for women, thereby increasing or reducing, respectively, the distress associated with realistic fear of rape. The guidelines outline participatory approaches that reduce the risk that aid is provided in harmful ways.

Interagency coordination is at the heart of efficient emergency response. Yet poor coordination of mental health and psychosocial support has been prominent in many emergencies because of institutionalized divisions in the humanitarian world. In most emergencies, two broad approaches emerge: one focused on clinical assistance through the health sector and the other focused on community self-help and social support activities organized by people working in the protection sector. Often these complementary approaches develop into independent sets of activities that compete for funding and influence. In numerous crises, this schism has led to separate coordination groups that do not communicate with each other.

The guidelines recommend a single, overarching coordination group and, where a single coordination group is unfeasible, advocate the establishment of subgroups that coordinate with each other. The guidelines describe an integrated framework within which divergent and complimentary approaches find a common home. The process of developing the guidelines has healed numerous interagency divisions in this young field. We call upon all agencies to implement these guidelines.

References

Available at: http://www.who.int/ bulletin/volumes/ 85/11/07-047894/en/index.html

References

1. Boothby N, Strang A, Wessells M, eds. A world turned upside down: social ecologies of children and war. Bloomfield, CT: Kumarian Press; 2006.

2. Miller K, Rasco L, eds. The mental health of refugees. Mahwah, NJ: Lawrence Erlbaum; 2004.

3. Mollica RF, Cardozo BL, Osofsky HJ, Raphael B, Ager A, Salama P. Mental health in complex emergencies. Lancet 2004;364:2058-67.

4. Van Ommeren M, Saxena S, Saraceno B. Mental and social health during and after acute emergencies: emerging consensus? Bull World Health Organ 2005;83:71-5.

5. IASC guidelines on mental health and psychosocial support in emergency settings. Geneva: Inter-Agency Standing Committee (IASC); 2007. Available at: http://www.humanitarianinfo.org/ iasc/mentalhealth_psychosocial_support

6. UNICEF. Symposium on the prevention of recruitment of children into the armed forces and demobilisation and social reintegration of child soldiers in Africa. Cape Town: UNICEF; 1997

7. WHO. The world health report 2001 – Mental health: new understanding, new hope. Geneva: WHO; 2001.

8. Galappatti A. What is psychological intervention? Mapping the field in Sri Lanka. Intervention: International Journal of Mental Health, Psychosocial Work & Counselling in Areas of Armed Conflict 2003;2:3-17.

9. Patel V, Araya R, Chatterjee S, Chisholm D, Cohen A, De Silva M, et al. Treatment and prevention of mental disorders in low-income and middle-income countries. Lancet. In press.

10. IASC. Guidelines for HIV/AIDS interventions in emergency settings. Geneva: IASC; 2003.

11. IASC. Guidelines on gender-based violence interventions in humanitarian settings. Geneva: IASC; 2005.

12. Jones L, Asare J, El Masri M,Mohanraj A Mental health in disasters: new humanitarian guidelines include the needs of people with severe mental disorders. BMJ 2007; 335:679-80.

a For task force membership and acknowledgements see http://www.who.int/ bulletin/volumes/ 85/11/07-047894/en/index.html.
a Task force members who developed the guidelines are: Allison Anderson [Interagency Network for Education in Emergencies (INEE)]; Cecille Bizouerne (Action Contre la Faim); Katy Barnett [Save the Children UK (SC UK)]; Martha Bragin (CARE Österreich); Fiorella Ceruti (World Food Programme); Lene Christensen [International Federation of Red Cross and Red Crescent Societies (IFRC)]; Henia Dakkak (United Nations Population Fund); Aidan Cronin [Office of the United Nations High Commissioner for Refugees (UNHCR)]; Nadine Ezard (UNHCR); Manuel Fontaine [United Nations Children’s Fund (UNICEF)]; Aminata Gueye (UNHCR); Lynne Jones (International Medical Corps); Kaz de Jong (Médecins sans Frontière-Holland); Lisa Long [Save the Children USA (SC USA)]; Marina Lopez Anselme (Refugee Education Trust); Amanda Melville (UNICEF); Mary Mendenhall (INEE); Jodi Morris (WHO); Kati Mosely (Mercy Corps); Pau Pérez-Sales (Médicos del Mundo); Bhava Poudyal (International Catholic Migration Commission); Joseph Prewitt Diaz (American Red Cross); Jorge Rodríguez (Pan American Health Organization); Janet Rodenburg (IFRC); Hakan Sandbladh (IFRC); Shekhar Saxena (WHO); Tanja Sleeuwenhoek (WHO); Marie de la Soudière [International Rescue Committee (IRC)]; Sarah Uppard (SC UK); Matthias Themel (CARE Österreich); Carl Triplehorn (SC USA); Unnikrishnan PV (Action Aid International); Mark van Ommeren (WHO); Vivien Walden (Oxfam GB); Jane Warburton (IRC); Jacqueline Weekers (International Organization for Migration); Mike Wessells [InterAction, Christian Children’s Fund (CCF)]; Wendy Wheaton (CCF); and Nana Wiedemann (IFRC). Consultants Nancy Baron, An Michels and Malia Robinson wrote drafts of one action sheet each. The task force wishes to thank everybody who has collaborated on the development of these guidelines.
1 Correspondence to Mark van Ommeren (e-mail: vanommerenm@who.int)