Integrative Mental Health and Psychosocial Support Interventions for Refugees in Humanitarian Crisis Settings: Integrative Health Care for the 21st Century Refugees

Abstract

Refugees are often exposed to various interrelated stressors including the loss of resources and belongings, death of, or separation from, loved ones as well as direct exposure to armed conflict and violence. Psychological distress is common amongst refugees, with a substantial percentage developing mild to moderate mental disorders such as depression or anxiety disorders. A small percentage of people in refugee settings have severe mental disorders (often exacerbations of pre-existing disorders) and they are especially vulnerable.

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© Springer International Publishing AG, part of Springer Nature 2019
T. Wenzel, B. Drožđek (eds.), An Uncertain Safety,
https://doi.org/10.1007/978-3-319-72914-5_6
I. Weissbecker (*)
Technical Unit, International Medical Corps, Washington, DC, USA
e-mail: iweissbecker@internationalmedicalcorps.org
F. Hanna
WHO Department of Mental Health and Substance Abuse, Geneva, Switzerland
e-mail: hannaf@who.int
M. El Shazly
Public Health Unit, United Nations High Commissioner for Refugees, Erbil,
Kurdistan Region, Iraq
e-mail: ELSHAZLM@unhcr.org
J. Gao
Centre for Global Mental Health, London, UK
P. Ventevogel
Public Health Section, United Nations High Commissioner for Refugees, Geneva, Switzerland
e-mail: ventevog@unhcr.org
6
Integrative Mental Health
andPsychosocial Support Interventions
forRefugees inHumanitarian Crisis
Settings
InkaWeissbecker, FahmyHanna, MohamedEl Shazly,
JamesGao, andPeterVentevogel
Abstract
Refugees are often exposed to various interrelated stressors including the loss of
resources and belongings, death of, or separation from, loved ones as well as
direct exposure to armed conict and violence. Psychological distress is common
amongst refugees, with a substantial percentage developing mild to moderate
mental disorders such as depression or anxiety disorders. A small percentage of
people in refugee settings have severe mental disorders (often exacerbations of
pre-existing disorders) and they are especially vulnerable.
This chapter outlines complex challenges in addressing the mental health and
psychosocial support (MHPSS) needs of refugees and describes key global
guidelines, programmatic elements and recommendations in the areas of MHPSS
including situational assessments, coordination of services and functional inte-
gration of mental health interventions within existing health systems. Various

118
specic intervention modalities will be discussed, including psychological rst
aid, scalable psychological interventions, community-based psychosocial work
and training of health workers in basic mental health care. This chapter has the
potential to inform the planning, implementing or researching of MHPSS con-
siderations for programmes in humanitarian refugee crises.
6.1 The Context ofRefugee Mental Health inHumanitarian
Crisis
6.1.1 Introduction
The world today is facing an unprecedented number of refugees and forcibly
displaced persons: estimated at over 65 million people worldwide [1]. The effects of
forced displacement and its subsequent stressors on mental health can be pervasive
and profound. In the past, some donors, academics and humanitarian decision-
makers assumed, mistakenly, that mental health problems were of less importance
compared to other health problems and that populations outside highly developed
industrial countries would not consider mental health and psychosocial wellbeing a
priority. However, eld experience and research have shown that people affected by
humanitarian emergencies do view mental health as a signicant issue of concern
[2–4]. As a consequence, over the last decade, attention to mental health in humani-
tarian emergencies has been increasing, whilst programmes for mental health and
psychosocial support have become routine elements of the humanitarian response to
refugee crises [5, 6]. The eld has evolved over the past several years and moved
away from being overly focused on psychological trauma, posttraumatic stress dis-
order (PTSD) and on specialised interventions by mental health clinicians from
high-income countries and has become a burgeoning eld of research and interven-
tions moving towards a more inclusive approach; one which recognises the scope
and signicance of different types of culturally shaped mental health problems and
one which seeks to develop existing strengths and build capacities over time in order
to integrate mental health care within already existing health, social and community
systems [7–10].
Increasingly, humanitarian responses now include programming for mental
health and psychosocial support (MHPSS). This often includes interventions in a
wide range of sectors and thematic areas such as health, education, community-
based protection, sexual and gender based violence, and child protection. There is
growing awareness that all staff involved in the humanitarian response should know
the basics of MHPSS and understand how their own actions can inuence mental
health and psychosocial wellbeing [11, 12]. All professionals working in humanitar-
ian emergencies can contribute to alleviating the tremendous psychological suffering
of the populations they serve.
Over the years, funding for mental health as part of development has slowly
increased [13], and major stakeholders are starting to realise the importance of
I. Weissbecker et al.

119
investing in mental health within refugee situations [14–16]. In practice, however,
mental health is often not given a high priority, and inclusion of MHPSS within donor
funding for humanitarian crises still often falls short of the total needs. In the 2016
Syrian Arab Republic Humanitarian Response Plan (SHARP), for example, MHPSS
represented less than 0.1% of the overall budget of the humanitarian response [17].
This chapter intends to outline basic principles to inform the planning, imple-
menting or researching of mental health and psychosocial support considerations
for programmes in humanitarian crises, particularly in situations of forced displace-
ment, with refugees and internally displaced persons (IDPs) in low- and middle-
income countries.
6.1.2 Stressors andMental Health Problems
Refugees and others affected by humanitarian crises frequently suffer various severe
and interrelated stressors including the loss of homes, livelihoods, material belong-
ings, communities and social support systems. They may also witness horric
events and atrocities, lose loved ones, become separated from family members.
Many refugees are at a greatly increased risk of physical assault, gender-based
violence and malnutrition [18]. Specic population groups such as children and
youth are especially vulnerable as they are often dependent on caregivers and may
become orphaned or separated in situations of crises.
Even when the acute emergency is over, the affected displaced populations
continue to experience signicant stress and hardships because of harsh living
conditions, the erosion of mutual social support mechanisms, limited access to
basic needs and services and lack of opportunities for maintaining livelihoods and
education. Health and social services, which existed before the crisis, have often
broken down whilst humanitarian aid attempts to ll the gaps. Poorly organised
humanitarian services may contribute to making problems worse and increase
tensions and stress in refugee populations [19]. It is often hugely challenging
to create available and acceptable service of good quality for refugees and other
displaced populations. Refugees may not be allowed to utilise local treatment
services, which may also be expensive, or they may not have access to services
outside refugee camps. Often, cultural and language barriers complicate the situ-
ation even further.
Many emotional, cognitive, physical and behavioural reactions are normal adap-
tive reactions to severe stressors; these are more likely to resolve if a supportive
family or community environment is available. Unfortunately, in humanitarian
settings, many of the protective informal community networks have deteriorated.
Some people are at increased risk of developing prolonged mental health problems
or disorders, especially those who already had difculties in functioning before
the emergency, those who have experienced cumulative stressors and those who
have limited social support. People may develop negative behaviours to cope with
stress such as the consumption of alcohol or drugs further putting them at risk [20].
People who have suffered mental health difculties in the past, or are suffering from
6 Refugee Mental Health and Psychosocial Support

120
a pre-existing mental disorder, may nd their symptoms relapsing or exacerbated.
Humanitarian emergencies cause high rates of distress although precise estimates
of prevalence are not known [21]. Nevertheless, only a minority of those suffering
distress will develop frankmental disorders as shown in Table6.1.
6.1.3 Global MHPSS Guidelines andApproaches
6.1.3.1 Key Definitions
Mental Health
Mental health is not just the absence of mental disorder. The World Health
Organization (WHO) denes mental health as a state of wellbeing in which every
individual realises his or her own potential, is able to cope with normal stresses of
life, can work productively and fruitfully and is able to make a contribution to their
community [23].
Mental Health andPsychosocial Support
Health agencies tend to speak of ‘mental health care’ to describe treatment interven-
tions for people with mental disorders. However, outside of the health sector, the
term ‘psychosocial support’ or ‘psychosocial intervention’ may cover a broader
range of activities that support both the psychological and social wellbeing of fami-
lies, groups and communities—not just those who suffer from mental disorders.
This binary has led to confusion in the humanitarian sector, and so many organisa-
tions have agreed to use the composite term ‘mental health and psychosocial sup-
port’ to indicate ‘any type of local or outside support that aims to protect or promote
psychosocial wellbeing and/or prevent or treat mental disorder’ [18].
Community-Based Approach
MHPSS places a large focus on the level of the community: a community-based
approach implies working closely with affected populations, recognizing their
individual and collective capacities and resources, and building on these to ensure
wellbeing and protection [24].
Table 6.1 WHO projections of mental disorders and distress in adult populations affected by
emergencies [22]
Before emergency:
12-month prevalence
After emergency:
12-month prevalence
Severe disorder (e.g. psychosis, severe
depression, severely disabling form of anxiety
disorder)
2–3% 3–4%
Mild or moderate mental disorder
(e.g. mild and moderate forms of depression
and anxiety disorders, including mild and
moderate PTSD)
10% 15–20%
Normal distress/other psychological reactions
(no disorder)
No estimate Large percentage
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Mental Health and Psychosocial Support Approach
The term ‘MHPSS approach’ is sometime used to promote the understanding that all
actions and interventions in a humanitarian setting may have effects on mental health
and psychosocial wellbeing, even if this is not the primary intention of the action
[25]. For example, building shelters for refugees has as primary aim to provide a safe
place to live, but the way in which such housing is realized can greatly affect psycho-
logical wellbeing. Consulting refugee communities and promoting active participa-
tion of refugees in the design and construction of their shelter, and ensuring that
marginalized or vulnerable sections of the population feel safe and included, may
create a sense of collective ownership and foster a sense of belonging.
Mental Health andPsychosocial Support Interventions
Whilst many interventions in a humanitarian setting may affect mental health and
psychosocial wellbeing, a core MHPSS intervention has the specic aim to contrib-
ute to improved mental health and psychosocial wellbeing [25].
6.1.3.2 IASC Guidelines onMental Health andPsychosocial Support
inEmergency Settings
In 2007, the Inter-Agency Standing Committee (IASC), the primary mechanism for
inter-agency coordination of humanitarian assistance, published the ‘Guidelines on
Mental Health and Psychosocial Support in Emergency Settings’. These guidelines rep-
resent a consensus framework that provides humanitarian actors with a set of minimum
multisectoral responses to protect and improve people’s mental health and psychosocial
wellbeing in emergencies. The guidelines include a matrix with recommended key
interventions spanning emergency preparedness, minimum responses during or after an
emergency as well as comprehensive responses including potential additional responses
for an emergency that becomes stabilised or is in the process of reconstruction. These
responses work across domains of coordination, human resources, community mobili-
sation, community support, health, nutrition and water and sanitation. Furthermore, the
guidelines emphasise collaboration between sectors and with non-health actors and core
clusters such as child protection, sexual- and gender-based violence, community-based
protection and education. They contain 25 action sheets placing an emphasis on multi-
sectoral and coordinated action. Each action sheet contains the following information:
background, key actions, selected sample process indicators, examples of good practice
in previous emergencies and a list of further resource materials [18].
The guidelines are useful for the planning and coordination of activities and pro-
vide organisations from various backgrounds with a common conceptual framework
for setting up services. IASC guidelines on MHPSS endorse six main principles:
human rights and equity, participation, do no harm, building on available resources
and capacities, integrated support systems and multilayered supports (see Fig.6.1).
A 2014 review of the IASC guidelines found that they helped strengthening the
role of MHPSS in emergencies, and the use of the ‘MHPSS’ term had improved
understanding and linkage between mental health and psychosocial actors [5].
Furthermore, the intervention pyramid (Fig. 6.1) was found as a useful tool in
training, coordination and discussions at the cluster level. Guidelines were found to
be helpful in the communication between agencies and donors and were inuential
in developing and disseminating MHPSS policies.
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6.1.4 Cultural Considerations
Clinical
services
Focused psychosocial
supports
Strengthening community
and family supports
Social considerations in
basic services and security
Advocacy for good humanitarian practice:
basic servies that are safe, socially
appropriate and that protect dignity
Activating social networks
Supportive child-friendly spaces
Basic emotional and practical support
to selected individuals or families
Clinical mental health care (whether by PHC
staff or mental health professionals)
Examples:
Intervention Piramid
Fig. 6.1 The intervention pyramid for MHPSS in emergencies [18]
Vignette: Cultural, Social and Contextual Factors
Khamis is a 35-year-old man in an East African country. He is married with
ve children. One year ago, he had to ee his native country due to ethnic and
religious violence. He witnessed the pillaging of his village, and several family
members were killed. One of his children died from illness during the ight.
He and his family have been in a refugee camp in a foreign country for 4
months. Khamis, who used to be a farmer and carpenter, cannot use his skills
because, as a refugee, he is not allowed to work. He and his wife argue much
more than before, and he sometimes beats his wife but feels bad afterwards. He
feels increasingly useless and has lost hope that his life will ever improve. His
appetite is not good and he does not sleep well. He does not want to show his
sadness, and in order to forget his problems he has started drinking excessively.
He frequently visits the health centre and a local healer to complain of tired-
ness and stomach pains, but they have been unable to help him.
Discussion: This patient, who may suffer from depression and alcohol use
disorder, does not self-identify as having a mental disorder and will be unlikely
to seek help from a mental health professional. However, he makes numerous
visits to the primary health-care provider for somatic complaints. Any adequate
solution for Khamis needs to take the individual, family and environmental con-
text into account and address both psychological and social problems.
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The way in which refugees experience mental disorders is strongly inuenced by
factors such as semiotics and the cultural meaning and signicance of concepts of
mental illness. Describing any disorder is inuenced by language and culture. In many
languages, the terms ‘mental disorder’ and ‘mental illness’ may translate to ‘crazi-
ness’ or ‘madness’, carrying strongly negative connotations and stigma. Such terms
are often only used for people with severe mental disorders. Causes for such disorders
are often seen as spiritual which results in those affected seeking help from traditional
healers and religious leaders. Mild and moderate forms of mental disorder—including
depression, anxiety and substance use disorders—are not always identied as mental
disorders but rather as social or moral issues or problems related to a person’s char-
acter. Those affected usually seek help from trusted community members or leaders
rst. Consequently, the way people dene ‘mental disorder’ has major implications
for their health and help-seeking behaviour. Worldwide there are major variations in:
• How problems of thinking, feeling, perceiving or behaving are described and
labelled
• Beliefs about the causes of mental disorders
• Coping mechanisms
• How mental distress is managed as part of formal services (e.g. health and social
services)
• How mental distress is managed as part of informal services (e.g. community
traditional or religious healers)
• How people with mental illness are perceived and treated within communities
People often use culturally patterned expressions to communicate that they ‘do
not feel well’ and are having difculty with the tasks and functions of daily living.
Often these are not discrete diagnostic categories with a specic set of symptoms
but are pragmatically applied concepts with uid boundaries. These idioms of dis-
tress may be indicative of strong emotional or psychopathological states that under-
mine the wellbeing of a person but do not necessarily imply that the person has a
mental disorder; in a lot of cases, these idioms are focused on a typical symptom or
localised to one area of the body. Some examples include:
• Idioms related to thoughts, e.g. kufungisisa meaning ‘thinking too much’ in
Shona in Zimbabwe and yeyeesi meaning ‘many thoughts’ in Kakwa in South
Sudan [26–28]
• Idioms related to the heart, e.g. poil-heart meaning ‘heavy hearted’ in Krio in
Sierra Leone, qalbi-jab meaning ‘broken heart’ in Somalia, qalb maaboud mean-
ing ‘squeezed heart’ in Arabic (referring to dysphoria and sadness) and houbout
el qalb meaning ‘falling or crumbling of the heart’ (referring to the somatic reac-
tion of sudden fear) [29–31]
• Idioms related to the head, e.g. amutwe alluhire meaning ‘my head is tired’ in
Nande in the Democratic Republic of Congo [28]
• Idioms related to the general body, e.g. jiu sukera gayo meaning ‘drying of the body’
used by Bhutanese refugee in Nepal to indicate a situation of loss and desperation [32]
or lashe mn grana meaning ‘my body is heavy’ in the Kirmanji Kurdish dialect [30]
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Health workers should make attempts to identify and understand salient local
idioms in the settings where they work. This can help facilitate more effective com-
munication with their patients through the identication of local coping methods
which may, in some cases, be more appropriate than Western interventions. For
example, poil-heart is described by an adolescent girl in Kailahun, Sierra Leone, as
‘Someone who is poil-heart is in a group but she’s withdrawn from it, she suffers
from something and does not pay attention. If she has a baby she is confused and
can neglect the baby. When she or he imagines what happened she cries all day and
cannot sleep or eat. She tries to work but it is no good. When she is at school her
concentration is poor’ [31]. On a supercial level, the problem seems to resemble
the psychiatric concept of ‘major depressive disorder’, but the people in Sierra
Leone did not see it as a problem that required professional medical or traditional
healing assistance. Thus the treatment for poil-heart was described as ‘... If my
friend was poil-heart I would go to her and talk with her to encourage her. If there
was a football game I would encourage her to go. If lonely I would ask her problems
and exchange ideas. If she told me she could not sleep or was afraid I would take her
to my bed and share it. One should hear the problem, explain it and solve it’. Western
therapeutic efforts and interventions should identify and support such positive and
constructive mechanisms which may already be in place, rather than assume that the
toolkit of medical psychiatry will always have the best and only solution [33].
This requires that MHPSS workers develop ‘cultural competence’ which is the
‘capacity of practitioners and health services to respond appropriately and effec-
tively to patients’ cultural backgrounds, identities and concerns’ [34]. Guiding prin-
ciples for cultural competence in disaster mental health programmes include
recognising the importance of culture and respecting diversity, obtaining knowledge
about the cultural composition of the community, recruiting MHPSS workers who
are representatives of the community and providing training and guidance to
MHPSS staff [35]. Besides, it is important to ensure that services are accessible,
appropriate and equitable and involve existing support networks. A way to do this in
refugee populations is to train and involve some of them as ‘cultural brokers’ or
‘cultural mediators’ as has been successfully introduced in new humanitarian set-
tings with refugees and migrants in Europe [36]; this has had a long antecedent in
humanitarian settings in low- and middle-income countries in which refugees or
other conict-affected people are often engaged as intermediaries between ‘popula-
tion’ and ‘services’.
6.1.5 Human Rights Considerations
Worldwide, people with severe mental disorders are at a higher risk for abuse and
neglect, such as physical restraining, seclusion or isolation and being denied basic
needs and human rights [37]. The widespread stigma and discrimination surround-
ing mental disorders prevent people from seeking and receiving care. In many
emergencies, human rights violations are particularly common due to increased vul-
nerabilities such as displacement, breakdown of social structures, violence, absence
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125
of accountability and a lack of access to health services and resources such as psy-
chotropic medication [38, 39]. It is important that MHPSS practitioners are aware
of the human rights frameworks and are able to go beyond narrowly dened clinical
approaches and collaborate with human rights advocates to address the range of
rights violations that people with severe mental disorders face [40–42]. This may
require using a more inclusive vocabulary that goes beyond medical terminology.
Those using human rights-based approaches often avoid terms such as ‘mental dis-
orders’ or ‘psychiatric disease’ and favour the terms ‘psychosocial disabilities’ and
‘mental disabilities’. This emphasises that the problem is more than an impairment
or disorder that resides in the individual but that disability is the result of an interac-
tion between impairment and attitudinal or environmental barriers which hinders
full and effective participation in society on an equal basis with others [41]. Using
a human rights perspective will emphasise the barriers which prevent people with
psychosocial or mental disabilities to enjoy full use of their rights including rights
for self-determination and making treatment decisions, as well as rights to fully
participate in society and to access key opportunities such as employment and edu-
cation. Barriers to realising those rights may be legal, economic and social and can
also be related to barriers within the health-care system. In humanitarian settings,
MHPSS practitioners, together with affected persons and their families, can raise
awareness and advocate for mental health policies and laws which promote the
improvement of human rights conditions for people with mental health problems
[43]. It is also important to involve people affected by mental illness and their fami-
lies in making sure programmes are designed to meet their needs and to foster par-
ticipation and leadership roles amongst mental health service users.
6.2 Key Aspects oftheMHPSS Response
6.2.1 Assessment
Before planning activities in mental health and psychosocial support, an assessment
should be conducted to gain a better understanding of the humanitarian situation, to
identify the priority issues around mental health and psychosocial support which
need attention and to evaluate the available resources. Such assessments should
focus both on needs and on available resources and include both nding new infor-
mation (through qualitative and quantitative means) and the systematic collection of
information that already exist. This includes general humanitarian assessments and
reports by non-governmental organisations [22] as well as a review of existing men-
tal health system information including World Health Organization Assessment
Instrument for Mental Health Systems (WHO-AIMS), WHO Mental Health Atlas
and other relevant documents [22, 44–46]. MHPSS assessments in humanitarian
emergencies are essential but also run the risk of causing harm by asking sensitive
questions and not having trained data collectors who can respond supportively and
link those with urgent needs to available services. Assessments which are not well
planned and informed by existing tools and ethical guidelines may not result in
6 Refugee Mental Health and Psychosocial Support

126
useful knowledge leading to uninformed planning or inappropriate interventions.
There are concerns that the preoccupation with individual psychopathological
responses, which characterise many assessments, may ignore the sociopolitical con-
texts, the various cultural idioms of distress, priorities of the affected population and
existing strengths and resources and do not translate into project planning [47–50].
It is therefore critical that assessments pay attention to aspects of coordination,
selection of appropriate measures and inclusion of contextual information as well as
adhering to key ethical considerations.
Coordination with other actors during an assessment is essential to maximise
resources, identify gaps and avoid duplication and burdening affected communities
with multiple questionnaires which may not result in appropriate services [47].
Assessments should be announced and planned with MHPSS coordination groups
in order to coordinate efforts with other humanitarian actors and agencies.
Additionally, assessments should coordinate with and engage existing stakehold-
ers—such as governments, communities and national and international agencies—
in initial discussions about needs and priorities. Lack of coordination during the
assessment phase may cause ‘assessment fatigue’ amongst refugees who are some-
times multiple times being asked similar things whilst they do not see any visible
improvements in their situation.
A set of key resources for assessment is readily available for MHPSS humanitar-
ian actors [22, 51, 52]. It is important to remember to choose relevant questions and
adapt them to the specic settings, avoid lengthily interviews and be aware of highly
sensitive questions which might put people in danger. A diverse range of groups
should also be considered and included in MHPSS assessments such as children,
youth, women, men, older people and other minority groups. Commonly used and
recommended global guidelines for MHPSS assessments in humanitarian settings
have been frequently used for assessing the needs of refugees [22, 51]. Tools and
questions cover the areas of:
• Relevant contextual information, e.g. culture-specic beliefs and practices, prac-
tices around death and mourning, vulnerable groups at risk and attitudes towards
severe mental disorder
• Experience of the emergency, e.g. perceived causes and expected consequences
• Mental health and psychosocial problems, e.g. culture-specic idioms of dis-
tress, priority mental health-related problems and impairment of daily activities
• Existing sources of psychosocial wellbeing and mental health, e.g. coping meth-
ods and community sources of support and resources
• Available services (e.g. 4Ws mapping, mental health checklists for health
facilities)
Desk reviews of existing resources can be important to synthesise what is
already known about cultural concepts and local beliefs and practices [53–56]. In
light of current humanitarian emergencies, several recent assessments highlight-
ing cultural and contextual aspects refugees have been produced, including on
Syrian refugees [30, 57], Somali refugees [29] and people displaced by the Nepal
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earthquake of 2015 [58]. The work of MHPSS actors can be synthesised using
the 4W mapping tool: ‘Who is doing What, Where and When’ [59–61]. Mapping
reviews of MHPSS actors and services have been regularly updated, for example,
for refugees in Jordan [62, 63].
Assessment reports have also examined the perceived physical, social and
psychological needs in refugee populations ranging from South Sudanese refugees
in Uganda to displaced Syrians and their host communities in Jordan [64, 65].
Assessments of local perceptions of the causes for different mental health problems,
and ways in which communities seek help, are also helpful for programme planning.
Amongst the Somali refugee population in Ethiopia, for example, depression is
thought to be caused by a loss of resources so community members try to help those
affected by replacing their lost belongings and providing social support [29, 66]. On
the other hand, psychotic disorders and epilepsy were seen to have spiritual causes,
and families of those affected often sought care from traditional healers. Rapid
MHPSS assessment reports combining review of existing documents, perceptions
of community members and available mental health and psychosocial support ser-
vices and capacities are also available [67–70].
Published assessments of mental health needs amongst refugees or other people
in humanitarian emergencies often focus on or include surveys examining the prev-
alence of specic mental disorders such as depression or PTSD [71–74]. However,
prevalence surveys are resource and cost intensive and often pose their own unique
challenges; among humanitarian agencies there is consensus that such epidemio-
logical surveys are not part of a routine assessment in emergencies [22]. In the past,
prevalence surveys in humanitarian settings have been unable to distinguish between
normal stress reactions and mental disorders leading to inated estimates [75].
These surveys often use symptom checklists which have been validated only in
Western settings and therefore may misclassify local expressions of mental disor-
ders [76] or miss important information [77]. Such local idioms of distress—includ-
ing concepts and experiences of mental health—may vary considerably from the
Western diagnostic categories of the Diagnostic and Statistical Manual of Mental
Disorder (DSM) or the International Classication of Diseases (ICD) [78–81].
Mental health symptom checklists have a large focus on psychopathology with little
attention to positive factors which drive wellbeing such as hope, social functioning
or social support [82]. Whilst surveys predominantly focus on psychiatric symp-
toms, which may help with advocacy for potential donors, they are of only limited
usefulness for programme planning. Generic WHO estimates of prevalence already
exist, as outlined earlier in this chapter (see Table6.1), and these are often sufcient
for the initial stages of programmatic planning.
Any assessment of mental health problems amongst emergency-affected popula-
tions needs to use instruments that are culturally validated for the local population
and should include severe mental health problems (e.g. impaired functioning,
bizarre behaviour, immediate danger to self or others) [18, 22]. Some researchers
have developed culturally and methodologically sound methods of assessing mental
health problems in varying contexts using mixed qualitative and quantitative meth-
ods of capturing local idioms and distress and can develop culturally relevant indi-
cators of functioning and validation measures for use [18, 83, 84].
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MHPSS research in humanitarian settings requires careful considerations of ethi-
cal issues given the population group under study. Guidance documents have been
developed for mental health research in humanitarian settings which are also rele-
vant for MHPSS assessments [47, 52, 85]. It has been recommended that research
should:
• Benet the affected population
• Use culturally valid assessment instruments and measures
• Consider power dynamics and the relative social statuses of researchers and
beneciaries
• Do no harm by protecting participants from potential negative effects of partici-
pation such as stigmatisation, discrimination and security threats
• Minimise psychological risks such as raised expectations and labelling whilst
ensuring review of research by affected communities
• Protect condentiality
• Involve affected communities in selection of research topics
• Obtain genuine informed consent (e.g. understandable explanations, avoiding
inappropriate incentives, repeating consent as appropriate)
• Share ndings with affected communities and make reports accessible to rele-
vant stakeholders and others in the eld
Too often, humanitarian or academic actors only use assessment ndings inter-
nally or publish ndings many months or years later. This can lead to duplication of
efforts and a less coordinated and informed response. After the assessment is com-
plete, it is therefore recommended to share it with other relevant agencies and stake-
holders and to disseminate recommendations for action. Several MHPSS assessment
reports using the tools discussed have been disseminated (e.g. via on dedicated Web
platforms for MHPSS in humanitarian settings such as www.MHPSS.net) or have
been published [64–66, 86].
6.2.2 Coordination
In humanitarian emergencies, coordination is essential between different actors to
share information, avoid duplication, ll gaps and advocate for best practices [18].
Coordination can also help ensure that different aspects of the humanitarian response
are implemented in a way which promotes mental health and psychosocial wellbe-
ing, ensuring that specic mental health and psychosocial interventions and mecha-
nisms are included in the humanitarian response [18]. National-level MHPSS
coordination groups are often jointly led by a UN agency (e.g. UNHCR, WHO) and
an international non-governmental organisation (INGO). They are closely linked
and coordinate with other groups such as health, protection and education; these
groups often take on important tasks such as producing brief inter-agency notes on
MHPSS for other actors, which include key points about best practices and guid-
ance tailored to a specic emergency based on global guidelines. Such guidance
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notes are the effort of multiple organisations and have in the past been developed in
settings such as Jordan, for the Syrian and Iraqi refugee response, Haiti after the
2010 earthquake and Gaza [87–89].
Coordination groups can also serve as an important platform to discuss proposed
MHPSS interventions from different actors in order to help ensure that global best
practice guidelines are followed as well as to provide orientation seminars and
information on these guidelines. In Jordan in 2012, for example, when Zaatari camp
for Syrian refugees was rst constructed, a foreign psychiatrist working at a eld
hospital proposed conducting a survey to assess the prevalence of mental illness in
the camp. The idea was discussed in the coordination group which also included
national actors from the Ministry of Health; it was agreed that such an assessment
would not be appropriate and that organisations would collaborate in developing
assessment methods and tools in line with the UNHCR and WHO MHPSS
Assessment Toolkit [22].
Another important function of coordination groups is the creation of referral
pathways and procedures between different local and international agencies. In
response to the Syrian refugee crisis in Greece, for example, the local organisation
Babel began a coordination group inviting different local and international mental
health professionals to discuss common problems, needs and pathways to refer
between different agencies. Gaps which were noted in referring refugees between
camps and urban sites were subsequently addressed in a project which funded men-
tal health outreach teams going from local urban-based organisations to camps. In
Jordan, the MHPSS coordination group has developed a common referral form for
mental health problems, including consent to refer and provide essential informa-
tion, which was then used by many different agencies [89]. This common referral
form together with a guidance note has more recently been further developed and
adapted for global use by the MHPSS IASC Reference Group [90].
6.2.3 Psychological First Aid (PFA)
In the aftermath of disasters there may be a range of direct and indirect sequelae
such as the loss of family members, loss of sense of control over one’s own life or a
lack of access to basic needs and social support; psychological consequences tend
to manifest in different ways and with a broad range of reactions, impacting not
only on the individual but also extending to wider layers of the general population.
These reactions are not necessarily pathological in nature and should not be regarded
as precursors to subsequent mental disorders. Adequate provision of support and
access to services will result in normalcy, fostering the healing process and resil-
ience of affected populations [91].
Large-scale disasters affecting large numbers of individuals necessitate the need
for basic supportive interventions which go beyond the bounds of psychotherapy or
professional counselling. Such basic support should not be provided only by spe-
cialised professionals but also by lay community members [91]. The need for such
early interventions, combined with the lack of evidence and potential for harm for
6 Refugee Mental Health and Psychosocial Support

130
single-session individual debrieng, has led to the development of psychological
rst aid (PFA) [92]. The term PFA encompasses a brief set of supportive, non-
clinical, response to a person who is suffering and who may require social or emo-
tional support [93]. It is meant to elicit feelings of safety, connection and self-help
in people recently exposed to serious crisis events to promote recovery. The action
principles of PFA are look, listen and link. PFA can be provided by anyone who is
in the position to help by:
• Providing nonintrusive, practical care and support
• Assessing needs and concerns
• Helping people to address basic needs (e.g. food and water, information)
• Listening to people but not pressuring them to talk
• Comforting people and helping them to feel calm
• Helping people connect to information, services and social supports
• Protecting people from further harm
It is important to realise that PFA is not akin to professional counselling or psy-
chological debrieng. It is based on robust principles that are rooted in evidence, but
until now there are not yet many quantitative data and a strong evidence base around
PFA in the scientic literature, and it is difcult to generate direct results for the
effectiveness of PFA [94, 95].
Because of its simplicity and utility, PFA has been recommended by many expert
groups [18, 96], and it has become one of the most popular interventions in the acute
phases of humanitarian crises [97, 98]. It has been translated in at least 20 different
languages, and specic adaptations have been made to address distress in children
and in the context of Ebola [99, 100].
6.2.4 Integrating withExisting Health Services
The above statement by a former director of the World Health Organization
was made at an international consultation in Geneva focusing on the impor-
tance of involving communities. Since then, these words have lost nothing of
“To address the mental health needs of large populations, we need denite
strategies and plans. Ad hoc arrangements and improvisations in response to
each emergency will no longer be acceptable. Specic management ability,
strong eld experiences and evidence-based approaches are required... WHO
strongly recommends the establishment of community-based mental health
care from emergency through reconstruction. Earliest integration of mental
health within the public health care system available in refugee camps and
national services is the most efcient, and cost-effective strategy. The con-
cerned communities must be mobilized and actively involved to decrease psy-
chiatric morbidity and increase sustainability.” [101]
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131
their urgency. Since 2000, the number of refugees and displaced populations has
soared, with many more and more protracted crises, and the recommendations
remain highly relevant.
6.2.4.1 Staffing andResource Shortage forMental Health
In today’s world, health systems, particularly in low- and middle-income countries with
a high number of refugees, face an unprecedented increase in need for mental health and
psychosocial support. According to the WHO Mental Health Atlas, more than 45% of
the world population are living in countries where there is less than one mental health
specialist for every 100,000 populations [45]. Huge inequalities in access to mental
health services exist depending on where people live. On average, globally, there is less
than one mental health worker per 10,000 people [102]. In low- and middle-income
countries, rates fall below 1 per 100,000 people, whereas in high-income countries the
rate is 1 per 2000 people. Worldwide nearly one in ten people have a mental health dis-
order, but only 1% of the global health workforce is working in mental health. Low- and
middle-income countries spend less than US$ 2 per capita per year on mental health,
whereas high-income countries spend more than US$ 50 [45]. The majority of spending
for mental health is on psychiatric institutions which only serve a small proportion of
those who need care. Task sharing of mental health care by non-specialised health pro-
fessionals as well as providing mental health care integrated with community-based
settings remains a key and cost-effective solution to bridge the gap in mental health
services and resources [103, 104]. In countries with many refugees, mental health ser-
vices require special considerations. Factors such as an increased prevalence of mental
health problems, weakened or overwhelmed mental health infrastructure as well as chal-
lenges of coordinating agencies and actors contribute to the difculties of providing
support for refugees [105]. On the other hand, postemergency reconstruction presents
signicant possibilities to raise awareness of the major gaps, worldwide, in the realisa-
tion of comprehensive, community-based mental health care. This is especially true in
low- and middle-income countries where resources are scant [106].
6.2.4.2 Common Challenges inIntegrating Mental Health Care
forRefugees
Refugee crises and other humanitarian emergencies create enormous challenges to
ensure even a minimum level of services for mental health and psychosocial sup-
port. In their attempts to alleviate suffering as rapidly as possible, humanitarian
programmes may inadvertently create problems on the long run such as (1) creating
parallel systems that are not sustainable and cause inequities between refugees and
non-affected local population or even undermine the existing mental health-care
system, (2) being driven by ‘outsiders’ and ignoring what people already do them-
selves and thus silencing or marginalising local perspectives and local views and (3)
providing insufcient supervision and follow-up training due to the short nature of
much humanitarian programming [107]. Many of these risks are not unique for
refugee settings, but they may become more pronounced and urgent in such situa-
tions. Common contextual challenges in providing integrated mental health care for
refugees include various interrelated factors as outlined below:
6 Refugee Mental Health and Psychosocial Support

132
Emergency contextual factors:
• Global political interest in an emergency usually attracts donors and brings more
funding opportunities (e.g. Syria crisis). Yet in several countries in Africa, large
emergencies with huge numbers of refugees (e.g. in Chad or Cameroon) remain
unnoticed [108].
• Protracted crises will suffer from gradually decreasing funding even if needs
remain large [109].
• Complex security situations which prevent access to certain geographical areas
will have a negative impact on training and supervision activities [110].
• Geopolitics and the historical nature of relationships between host populations
and refugee populations can contribute to conict, tensions and additional
stressors.
Refugee population-related factors:
• Access to services may be impacted by language barriers and limited command
of the host population language. Even if interpretation is available, the lack of
direct communication may complicate proper assessments and establishment of
supportive client-provider relationships.
• Cultural expectations are also important to consider. Refugees may have differ-
ent cultural beliefs about causes and treatment of mental disorder and their own
views on what to expect from mental health care and on what kind of information
they want to disclose. This may impact on whether they accept a mental health
diagnosis and the consequent treatment.
• Cultural belief systems of help seeking and coping amongst refugees may differ
from what is common in the host country. Different belief systems may hinder
mental health assessments and conict with the practitioners’ understanding,
such as the possible tendency to seek physical explanations for psychological
problems and to seek out traditional healers for severe mental illness.
• Refugees may be particularly distrustful of services and authorities because of
previous negative experiences in their country of origin or in the host country.
Moreover, they may be unfamiliar with the health-care system in the host coun-
try, in particular with the way mental health care works.
• In urban areas, there may be other factors hindering access for refugees such as
cost of treatment or medications and cost of transport (e.g. the nearest service
provider may be in another city).
Host country-related factors:
• The quality of social services in host country can also have an impact. A study of
refugees from the former Yugoslavia, conducted 9 years after the end of the
Balkan war, showed the importance of the support provided in the host country.
Lower mental disorder rates were linked to being in employment, having appro-
priate living arrangements and feeling accepted in the host country [111]. This
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133
would also be consistent with the nding that on the other hand continued daily
stressors increase the risk for mental health problems amongst conict-affected
populations [112–114]. Many low- and middle-income countries, hosting the
majority of the world’s refugees, do not have effective mental health systems to
absorb the increased needs.
6.2.4.3 Clinical Tools forMental Health inLow-Resource Settings
Training of general health care staff in mental health is critical to building capacity
for recognising and treating persons with both severe and common mental disor-
ders. In 2010, the WHO launched the Mental Health Gap Action Programme
Intervention Guide (mhGAP-IG) for mental, neurological and substance use disor-
ders in non- specialised settings; its newest version was published recently [115].
The mhGAP- IG presents integrated management of priority conditions using proto-
cols for clinical decision-making. The target audience of mhGAP-IG are non-spe-
cialised health-care providers working at rst- and second-level health-care facilities
in low- and middle-income countries. These include primary care doctors, general
practitioners, nurses and other members of the health-care workforce who are not
specialized in treating mental health problems. Currently mhGAP-IG is being used
in more than 100 countries, and mhGAP materials have been translated into more
than 20 languages. The WHO and UNHCR published a specic mhGAP module for
the Assessment Management of Conditions Specically Related to Stress [116].
This module was then incorporated into the mhGAP Humanitarian Intervention
Guide to address specic challenges of humanitarian emergency settings [117].
This humanitarian version is even more succinct than the regular version of the
mhGAP Intervention Guide and can be seen as stepping stone to the full mhGAP.The
conditions and chapters included in mhGAP-HIG are shown in Table6.2.
6.2.4.4 Principles ofIntegration Mental Health into General
Health Care
The World Association for Family Doctors together with the World Health
Organization has developed a report highlighting principles as well as case studies
for mental health integration into primary health care. These ten principles are cen-
tral for the successful integration into primary health care and bear special relevance
to countries with a large number of refugees (Table6.3).
Table 6.2 Modules in the mhGAP
Humanitarian Intervention Guide [117]• Acute stress
• Grief
• Moderate-severe depressive disorder
• Posttraumatic stress disorder (PTSD)
• Psychosis
• Epilepsy/seizures
• Intellectual disability
• Harmful use of alcohol and drugs
• Suicide
• Other signicant mental health complaints
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Table 6.3 Principles of mental health integration into primary care [118]
WHO/WONCA principles
of mental health
integration into primary
health care
Relevance to the context of integration of mental health into
primary health care in refugees contexts
Policy and plans need to
incorporate primary care
for mental health
National policy and plans need to consider universal access to
health-care services to all persons in the country, including
refugees, and must ensure the system is enabling access to refugees
at equal or lower costs than the host population
Advocacy is required to
shift attitudes and
behaviour
Refugees with mental disorders may suffer from dual discrimination
limiting access to health care, rst as a refugee and second as a
person living with mental disorder
Adequate training of
primary care workers is
required
Training of health workers on recognition of various cultural
presentation of symptoms as well on the available range of services
for the refugees in community
Primary care tasks must
be limited and doable
Experts can use available tools (e.g. mhGAP-HIG) which focus on
selected group of priority mental health conditions
Specialist mental health
professionals and
facilities must be
available to support
primary care
Involvement of specialists from the refugee population to support
on the job training and management of complicated cases.
Recruitment of health staff and community health workers
(CHWs) amongst the refugee population and involvement of the
refugee community leadership in coordination will ensure a
health-care programme that is culturally appropriate, accessible and
affordable [119]
Patients must have
access to essential
psychotropic
medications in primary
care
Mental health professionals should adapt pharmacological and
psychological interventions to the culture and needs of the refugee
population. Programmes should adhere to national and global
guidelines on which psychotropic medications to include and work
towards sustainability of medication supply. Professionals should
also be aware of the substantial variation of psychopharmacological
responses across cultures and ethnicities
Integration is a process,
not an event
The integration process can take several years and requires
advocacy targeting decision-makers as well as at donors. Public
health programme planers and implementers can use demonstration
pilot projects as proof of concept to attract further support and funds
for mental health reform and scale-up of services for refugees as
well as for host population [106]. Important is to take explicit
actions against inadvertently favouring pharmacological solutions
as a ‘quick x’ above more appropriate psychological and social
interventions [120]
A mental health service
coordinator is crucial
Optimise the coordination of services. Research has shown that in
almost all Western countries, experts identify the fragmentation of
care systems as a major problem for marginalised groups, such as
refugees [121]. Coordination should include specialised as well as
generic services
(continued)
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135
6.2.4.5 Health Professionals Amongst theRefugee Population
Supporting Other Refugees
In Turkey, during the Syrian Crisis, the Ministry of Health together with the
International Humanitarian Community is building the capacity of Syrian doctors
living in Turkey using mhGAP-IG to provide services at migrant health centres to
Syrian refugees. Another strong example comes from Syria itself. In 2011, before
the Syria conict, UNHCR and the International Medical Corps in Syria were
already in the area, operating comprehensive mental health and psychosocial sup-
port programmes for Iraqi refugees who were already in the country. When the cri-
sis started, the Syrian population had increasing mental health needs. In 2012,
programmes were expanded to support Syrians affected by conict through a mix-
ture of (mobile) individualised case management, family- and community-level
supports provided by outreach volunteers and targeted assistance to displaced per-
sons living in collective shelters [121].
6.2.4.6 Utilising Refugee Crises asanOpportunity toFoster Mental
Health System Reforms
Whilst providing comprehensive and culturally appropriate and sustainable mental
health services to refugees poses numerous challenges, refugee setting can also pro-
vide opportunities that, paradoxically, provide ingredients for structural improve-
ment of mental health services such as increased funding opportunities, an inux of
good human resources and an increased awareness of the importance of mental
Table 6.3 (continued)
WHO/WONCA principles
of mental health
integration into primary
health care
Relevance to the context of integration of mental health into
primary health care in refugees contexts
Collaboration with other
non-health sectors,
non-governmental
organisations, village
and community health
workers and volunteers
is required
Refugees can present with complex medical and nonmedical needs.
Medical needs can include infectious diseases, non-communicable
diseases and complications from injuries due to trauma, including
torture and violence. Reasons for the complexity of medical needs
include the high burden of disease in the country of origin, the lack
of access to health care and other pre- and post-migration stressors.
Nonmedical needs can include housing, employment and education.
The integration of services for refugees who have mental disorders
typically requires collaboration amongst various sectors and
stakeholders, both specialist and non-specialist health services
providers, service users, family and friends, community leaders,
education and employment services. Governmental health services
(e.g. public health justice system, child welfare, disability,
transportation) as well as non-governmental organisations (e.g. UN
agencies, legal aid, protection services, gender-based violence
programmes) also need to be involved
Financial and human
resources are needed
Funding is required to establish and maintain care services for large
number of refugees, to mainstream interpreting services and to
provide and disseminate information to both refugee groups and
professionals
6 Refugee Mental Health and Psychosocial Support

136
health and psychosocial wellbeing, sometimes generated through media attention
on the topic [122, 123]. The availability of such factors, in otherwise disadvantaged
or marginalised regions, can provide real opportunities to start new initiatives that
boost mental health care, and the massive needs arising in acute refugee settings
may prompt health authorities to accept piloting new initiatives for mental health-
care provision, including the training of general health workers, the use of para-
medical staff and working closely with communities which may provide the impetus
to include mental health care in health sector reforms [124–129]. This can lead to
real change as has been demonstrated by the case studies of ten emergency- affected
populations collected in the WHO publication Building Back Better: Sustainable
mental health care after disasters [106]. Enablers of integrating refugee services to
health-care services include:
• Sufcient funding
• Refugee and host population champions
• Government buy-in and support for need of mental health services
• MH services integrated with existing systems that serve both refugee and host
populations (rather than parallel mental health services only for refugees)
• Good service organisation
• Good rollout of both training and supervision [130–133]
The Middle East and North Africa region is one of the largest sources of refugees
and IDPs due to the crises in Iraq, Syria, Yemen and Palestine; the region corre-
spondingly also hosts most refugees. The mental health systems in this region are
typically reliant on large psychiatric institutions centralised around major cities
with limited community mental health services. The inux of large number of refu-
gees in countries such as Jordan and Lebanon has brought several challenges as well
as several opportunities [8]. If such opportunities are utilised, real change can hap-
pen as is illustrated in the following vignettes.
Vignette: Introducing Community-Based Mental Health Services in Jordan with
Iraqi Refugees
Displaced Iraqi refugees in Jordan have received substantial support from sev-
eral aid agencies. Within this context community-based mental health care
was initiated, and a new mental health unit was established within the Ministry
of Health to lead mental health governance. One of the challenges to mental
health reform in Jordan—as in other countries—was the initial reluctance
amongst many mental health specialists. Historically, psychiatrists were the
sole professionals treating people with mental disorders, and their main
approach was through a biological model. The reform has posed a challenge
to this approach as it promoted comprehensive, biopsychosocial interventions
emphasising the role of multidisciplinary teams; the reform also focused on
the integration of mental health services at a primary health-care level for the
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137
rst time and advocated for providing care for selected priority mental health
conditions using general practitioners. This challenge was addressed through
several means: involving all psychiatrists in the reform process, relying on
supportive ‘champions’ to serve as change agents within their elds, harness-
ing the motivation and determination of other mental health professionals to
support reform and beneting from strong support at the highest political
level [106].
Discussion: The Middle Eastern region represents the largest source of
displaced people as well as the largest host of refugees. In each of the refugee-
hosting countries, there are unique health systems; however mental health
systems in the Middle East are typically reliant on psychiatric hospitals, cen-
tralised around major cities with limited community mental health services.
An inux of refugees thus brings not only challenges but opportunities to
develop these services and to ‘build back better’ [106].
Vignette: Reform of Mental Health Care of Lebanon Following Syrian
Refugee Crisis
In Lebanon, with more than 1 million Syrian refugees (about one fourth of the
population), the Ministry of Public Health has identied a wide gap in mental
health services and decided to respond to the urgent need to strengthen the
mental health system in the country [134, 135]. The National Mental Health
Plan supported by organisations and agencies such as WHO, International
Medical Corps and UNICEF was launched to reform the mental health system
in the country [122]. Additionally, the Ministry of Public Health established a
Mental Health and Psychosocial Support Task Force. This task force currently
includes more than 60 organisations working on the Syrian crisis response in
Lebanon with the aim of harmonising and mainstreaming mental health and
psychosocial support in all sectors and improving access to care. One of the
highlights of Lebanon’s Mental Health Action Plan—which was unique in the
Middle Eastern region—was the adoption of a human rights perspective as a
cornerstone of the strategy. Equally the strategy highlighted not only the men-
tal health of refugees but also of other vulnerable groups including other dis-
placed populations (e.g. Palestinian refugees); persons in prisons; survivors of
torture; families of those enforcedly disappeared; the lesbian, gay, bisexual
and transgender community; and foreign domestic workers. Lebanon’s
Ministry of Public Health, together with international partners, is using
mhGAP-IG to integrate mental health services into primary health-care facili-
ties in order to provide services to both the host population and refugees.
Discussion: The importance of working with host communities has been a
large part of the Middle Eastern refugee response. For example, before the
Syrian conict organisations such as UNHCR and International Medical
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138
6.2.5 Scalable Psychological Interventions
Existing specialised human resources, such as psychologists and psychiatrists, are
often limited in refugee settings, and existing health systems, including mental health
services, can be overwhelmed or unavailable for refugees (e.g. due to distance, cost).
Nevertheless, the mental health needs are likely to be high in this population. One of
the most effective and cost-efcient ways to make psychosocial interventions avail-
able and accessible to refugees is to train non-specialised staff in delivering basic
interventions. Whilst several intervention studies targeting common metal health
problems (e.g. anxiety, PTSD, depression) amongst refugees have been published,
the intervention manuals used in these studies are rarely made public or shared with
other agencies. There is a signicant need to develop more evidence- based, cultur-
ally adapted and publicly available interventions which can be used by non-special-
ists. A number of evidence-based psychological therapies have been introduced into
humanitarian settings in the last few years [141–145]. There is good evidence for
their effectiveness in high-resource settings, whilst the evidence in crisis-affected
settings is still limited but promising. These interventions can be adapted for use by
trained and supervised non-specialists; however one major challenge is to ensure that
such interventions are not used as ‘stand-alone therapies’ or to be seen as quick xes
for complex problems. Brief evidence-based psychotherapies can be used if they are
contextually well adapted and functionally integrated within sustainable systems of
care with appropriate training and supervision by more specialised professionals.
Problem-Solving Counselling or Therapy Problem-solving counselling or ther-
apy is a psychological treatment involving the offering of direct and practical sup-
port. The service provider and person work together to identify and isolate key
problem areas that might be contributing to the person’s mental health problems.
This is done in order to break the problems into specic, manageable tasks and to
Corps were already working in the area operating a comprehensive mental
health and psychosocial support programme for Iraqi refugees [136, 137].
When the crisis began and mental health needs were further increasing, an
MHPSS programme was already well established through the resources and
capacities of the Iraqi refugee population. Therefore in 2012, existing pro-
grammes were expanded to support displaced Syrians affected by conict
through a mixture of mobile, individualised case management and family-
and community-level supports provided by outreach volunteers [138].
Equally, the resources and skills of the refugee population should not be
underestimated: in Turkey, during the Syrian conict, the Ministry of Health
together with the international community built on the capacity of Syrian doc-
tors living in Turkey to provide services at migrant health centres for Syrian
refugees, using mhGAP-IG [139, 140].
I. Weissbecker et al.

139
problem-solve and develop better coping strategies overall. It can be used as an
additional treatment option for depression and as a treatment option for alcohol use
disorders or drug use disorders. WHO has recently developed Problem Management
Plus (PM+) [146], a brief, non-specialist-delivered basic version of cognitive behav-
ioural therapy (CBT) for adults in communities affected by adversity [146]. It is
designed to address psychological and social problems through problem-solving
counselling plus a range of interventions such as stress management, behavioural
activation and strengthening social support systems. PM+ can be used with people
experiencing a range of common mental health problems—such as depression, anx-
iety and stress—at different symptom severity levels. Initial research has found that
PM+ is a promising intervention for reducing depression and anxiety symptoms in
conict-affected populations and there is potential for further developing and scal-
ing up this intervention targeting refugee populations [147–150].
Interpersonal Psychotherapy (IPT) Interpersonal psychotherapy is a time- limited
psychological treatment for depression, bipolar disorder, PTSD and other conditions
[151]. It focuses on the links between the person’s problems with functioning, mental
health symptoms and interpersonal crises—such as loss, conicts with others, social
isolation and life changes. IPT can be conducted individually or in groups, and in
community, clinical, primary care or other settings. In high-income countries, IPT is
typically provided by clinicians. Evidence from low- and middle- income countries sug-
gest that it is possible to train non-specialists, such as primary care staff, community
health workers, community psychosocial workers and others, to successfully help peo-
ple with depression in 8–16 session group IPT [150–153]. In Lebanon, IPT training has
recently been provided to various non-specialised psychosocial workers and case man-
agers addressing the needs of Syrian refugees and the vulnerable host community [154].
Interventions for Families There is a need for additional interventions to be
developed including interventions focusing on families. Recent research on conict-
affected children found that important mediators for the relationship between armed
conict and a child’s wellbeing include family variables such as harsh parenting,
parental distress and the witnessing of intimate partner violence [155]. Furthermore,
research has shown that parental mental health has consistently been found to pre-
dict child mental health in conict-affected and refugee settings [155]. Therefore,
efforts to improve child mental health should engage thoughtfully a consideration of
mental health and psychosocial family wellbeing across generations. Most psycho-
social interventions for children in conict-affected settings have focused more nar-
rowly on children rather than on their families and their broader environments
[156]. Few case studies have described the use of family therapy in conict-affected
settings, and this is an area where more research is needed [157, 158].
Interventions for Harmful Use of Alcohol and Drugs Harmful use of alcohol and
drugs is an often-neglected consequence of displacement given that those affected often
seek to cope with the past and existing stressors using drugs or alcohol [159–162]. Factors
that could drive people to abuse of alcohol and substance include higher levels of stress,
6 Refugee Mental Health and Psychosocial Support

140
unemployment and lack of livelihoods and problems in coping with a new environment
and often a new culture [20]. Substance use problems can develop in the country of ori-
gin, in transit, in temporary refuge or in resettlement. Particularly at risk are men and
those exposed to war trauma and people with coexisting mental health problems [163–
165]. Much less is known about alcohol and drug use patterns amongst children, adoles-
cents and women refugees. Adolescents and young adults could be specically vulnerable
considering the fact that these age groups are more vulnerable to drug use and disruption
of social norms and family structure can add to this vulnerability.
Evidence-based approaches, such as screening followed by motivational inter-
viewing or community self-help groups, show promise, but there is a need for a
greater evidence base of interventions at the community level to address this prob-
lem in crisis-affected populations [160, 166, 167]. In practice, interventions for
alcohol and substance disorders are often neglected in humanitarian settings [168].
Solutions likely require multilevelled interventions that include training health
workers in identication and management of substance use problems accompanied
by policy measures to restrict marketing and sales of drug and alcohol and with a
strong involvement of communities [169, 170].
6.2.6 Community-Based Psychosocial Work
One of the main problems in societies affected by chronic adversity, including armed
conict and forced displacement, is the rupture of the ‘social fabric’. As a result,
people begin to lose trust in each other and mutual support systems which had existed
before the crisis do not function anymore [4, 171]. Interventions to strengthen social
support, mutual trust and solidarity are usually not seen as the unique responsibility
of health actors, who tend to focus on the dysfunctional individual rather than the
dysfunctional group or community. In many humanitarian emergencies, social and
community interventions belong to the realm of specialists outside of the health sec-
tor such as in community-based protection, child protection or community mobilisa-
tion. It is, however, important for health workers to be aware of the social effects of
humanitarian emergencies and to liaise with and connect people to agencies and
groups involved in social interventions. Important elements include the use of par-
ticipatory approaches and the promotion of community organisation, ownership and
empowerment [172]. A key approach is to foster self-help within local communities
as much as possible and to make use of internal support structures amongst displaced
populations. With a greater involvement, people become more hopeful, more able to
cope and more active in rebuilding their own lives and communities [173]. Community
mobilisation and support are critical to care for people with mental distress or disor-
ders. Key actions to include communities are listed below:
• Avoid doing what local people can do for themselves—and instead build on what
local people are already doing to help themselves, including using internal com-
munity resources, knowledge, individual skills and talents.
I. Weissbecker et al.

141
• Support community initiatives and encourage additional ones to promote family
and community support for all emergency-affected community members, includ-
ing people at the greatest risk.
• Use multifunctional teams in UN agencies and NGOs in emergency settings.
• Use participatory and community-based approaches within a rights-based frame-
work (e.g. if certain groups appear to be marginalised or excluded, nd respect-
ful ways to include them in decision-making processes, including people with
mental disorders and their caregivers).
• When necessary, advocate within and beyond the community on behalf of mar-
ginalised and at-risk people such as people with severe mental disorders.
• Address human rights abuses in sensitive and culturally competent ways and
address stigmatising or abusive practices [174].
Much of this can be achieved through community-based protection, a multi-
leveled approach which may be used in refugee contexts. The approach works to
provide services that are urgently required to prevent threats and abuses whilst
also implementing programmes to enable people to improve their situation and
restore dignity [173]. Finally, community-based protection action allows the
changing of the underlying circumstances which obstructs a person’s ability to
realise their human rights. These levels are all strengthened via the active involve-
ment and input of the community; the capacities, agency, rights and dignity of
people are at the centre of programming [24]. Within the humanitarian response,
such actions are not always explicitly labelled or framed as ‘psychosocial’, but
they have, nevertheless, important effects on the psychosocial wellbeing of refu-
gees and other forcible displaced populations. Some examples of this type of
action are below.
Child-Friendly Spaces In the chaos of humanitarian emergencies, particularly in
the early stage when comprehensive services are still being set up, the needs of
children and young people can easily be overlooked. Displaced families and
humanitarian workers have many competing priorities such as registration, provid-
ing food and shelter and ensuring access to other basic services including health
care. Such contexts can constitute an unstable and stressful environment which
negatively affects the emotional and social wellbeing of children who have already
endured difcult events and hardships. Child wellbeing is often best fostered by
the restoration of a sense of normalcy and safety in crises. For example, schools are
often not yet established in the beginning of a refugee crisis and parents are often
overwhelmed. A widely used intervention for children in emergencies is the estab-
lishment of child-friendly spaces. These are ‘specic, identiable spaces that pro-
tect children and young people from physical harm and psychosocial distress
whilst assisting them to play and develop through participation in organised and
supervised activities during emergencies’ [175]. Child-friendly spaces are often
hosted in temporary structures, such as a large tent or container, and provide a sup-
portive environment in which children, under the supervision of trained facilita-
tors, can be engaged in a range of activities including song, drama, dance, drawing,
6 Refugee Mental Health and Psychosocial Support

142
play, storytelling/reading, sports as well as learning basic literacy and numeracy.
Child- friendly spaces have multiple goals that are not all strictly related to MHPSS
in a narrow sense but also goals related to provision of physical protection and
detection of children with specic needs, acting as a rallying point for community
mobilisation or providing some emergency education activities. [176]. They are
generally assumed to have a positive effect on the emotional wellbeing of children,
but the evidence base for this is still rather limited [177]. Recent rigorous long-
term evaluation of child-friendly spaces in various emergencies has shown positive
effects, but not for all children in all settings.
Refugee Outreach Volunteers In many refugee operations, refugees are engaged
as volunteers into a wide range of programmes in health, education and social ser-
vices. Particularly in non-camp environments, where refugees would otherwise
have difculties in accessing services for themselves, the establishment of network
of refugee outreach volunteers has proven to be of critical importance. Refugee
outreach volunteers constitute a link between the professional humanitarian ser-
vices and the refugee community. When programmes for refugee outreach volun-
teers are set up, psychosocial elements can be integrated in the training and
supervision of the volunteers who can then be involved in information sharing, link-
ing people to mental health services when needed and setting up support groups
amongst other functions [138, 178, 179].
Community-Based Sociotherapy In Rwanda, a community-based group
approach, community-based sociotherapy, was introduced in 2005 to address the
social and psychological consequences of the 1994 Rwandan genocide [180].
Groups of community members, with different personal histories of adversity and
suffering, share daily problems in weekly group meetings over 15weeks. These
problems can range from problems of family conicts, fear, mistrust, gender-based
violence, stigma and poverty. Through this process, the group functions as a thera-
peutic medium and facilitates the development of peer support structures. The
groups are guided by trained facilitators who aim to create a safe environment where
trust, care and respect can be built and rebuilt and where broken social relations can
be restored [181]. The focus of sociotherapy is on the relationships between people
rather than on individual symptoms, but there is some evidence to show positive
effects on mental health symptoms as well [182, 183]. Whilst this approach was not
initially developed for refugees, the method of community-based sociotherapy has
been successfully adapted for use with Congolese refugees to Rwanda [184].
Narrative Theatre This approach uses community theatre to assist communities
to identify and discuss common issues which are at stake in the community. The use
of communal techniques creates a social space where people can exchange stories,
discuss problems and share experiences from different perspectives. Participants
both tell their stories and act them out in interactive theatre. Narrative theatre is usu-
ally done in environments characterised by poor resources, disrupted social net-
works and dependency on aid agencies and in areas of high psychosocial and
I. Weissbecker et al.

143
physical problems, such as refugee camps or post-conict settings [185–187]. More
research is needed to investigate the effects of methods focused on collective heal-
ing on mental health and psychosocial wellbeing.
Working with Traditional Healers The involvement of community traditional
healers can be important for providing culturally relevant mental health care.
Healers can provide valuable insights on local beliefs, local terms used to describe
symptoms and idioms of distress as well as information about identifying clients; in
many cultures, people will go to these healers before instead of using Western medi-
cal approaches and seeking care at health centres. Involvement of traditional healers
can be very successful but can also be marred with complexities [188, 189]. A col-
laborative system, with cross referrals, creates opportunities for mutual learning
about benecial treatments, addressing inappropriate and harmful practices, improv-
ing public health education (e.g. via conveying messages regarding misuse of alco-
hol or drugs) as well as getting support for follow-up of cases (e.g. administering
and monitoring chronic treatment).
6.3 Future Directions andRecommendations
This chapter has outlined the complex challenges of addressing mental health
amongst refugee populations including contextual factors (e.g. limited mental
health systems in host countries, cultural barriers) and often limited donor funding
and attention to mental health. We have also outlined key programmatic elements
and recommendations in the areas of MHPSS assessments, coordination, psycho-
logical rst aid, integration with existing health systems, scalable psychological
interventions and community-based psychosocial work.
Past research on MHPSS in refugee settings has focused on establishing preva-
lence rates of disorders such as PTSD or has evaluated the effectiveness of special-
ised interventions delivered by professionals. It is now time to move on to broader
and more operationally relevant research [144] and for researchers to engage with
contemporary notions of resilience and social ecology [158, 190, 191]. For exam-
ple, it is important to shed more light on question about how changes in the social
environment can inuence individual wellbeing and to investigate the effectiveness
of interventions such as training parents of distressed refugee children and of other
family- and community-focused interventions.
There is also especially a need for innovative and methodologically sound
research on scalable low-cost mental health interventions that can be delivered by
non-specialists (e.g. health staff, teachers, community health workers and other
community workers) [192]. It has, by now, been well established that incorporating
basic psychiatric services into general health care within humanitarian emergencies
is possible, but little is known about if and how such interventions can be brought to
scale and be incorporated in sustainable routine systems of care without unaccept-
able loss of quality [193, 194]. Similarly, there is now solid evidence that brief
psychological interventions delivered by trained non-specialists yield remarkable
6 Refugee Mental Health and Psychosocial Support

144
results in research trials [195]. However, it remains a challenge to scale up and inte-
grate such interventions without losing quality. Implementation research is needed
that addresses questions around scale-up, supervision, staff retention and quality
control [196].
Key features of effective MHPSS interventions include community engagement,
partnership with government and/or local actors, delivery by trained providers,
socially and/or culturally meaningful programme activities, being group based and
programme providers who build trusting and supportive relationship with pro-
gramme recipients [197].
Lastly, it is essential to make research ndings accessible to implementing
organisations such as international and local NGOs through open-access jour-
nals and to foster collaborative research involving national actors and including
refugees [198, 199].
The eld of mental health and psychosocial support for refugees has gained in
strength, but the danger of losing momentum continues. We feel that real opportuni-
ties exist to include quality interventions within the humanitarian response for refu-
gees in resource-constrained settings. This will require concerted efforts by
researchers, practitioners and policymakers.
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