Creative tensions in the framing of MHPSS

The tensions and challenges involved in the development over recent decades of the field of practice now known as mental health and psychosocial support (MHPSS) will continue to shape questions of implementation, prioritisation and impact.

The earliest use of the term ‘psychosocial’ in the context of forced migration that I have found is by Hertha Kraus in a 1939 Special Issue of the The Annals of the American Academy of Political and Social Science.[1] Her paper addressed the sources of stress for those resettling in “a strange country” and noted the psychological and social nature of these beyond the legal, political and economic stressors considered by other authors.

The term only came into wider use in the field in the 1990s, however. Barbara Harrell-Bond had written a chapter in her 1986 classic Imposing Aid on “the over-socialized concept of man” in which she had taken the humanitarian field to task for its neglect of the psychological experience of forced displacement. In 1993 I was asked by her to put together a review of the issue of refugee mental health for Harvard’s Global Mental Health report.[2] However, it made only passing reference to the psychosocial concept, largely to hint at the broader social and cultural context shaping refugee mental health.

A subtle hint was inadequate to address the divisions that developed in this fledgling field later in that decade. The Rwandan genocide and, particularly, the wars following the breakup of the former Yugoslavia brought the human side of conflict and displacement into both public awareness and humanitarian response. However, addressing mental health issues in populations subject to ethnic-political persecution also brought to the surface sharp tensions between normative psychiatric responses and broader community-based approaches.[3] Derek Summerfield and Pat Bracken were particularly strong critics of the imposition of Western frames of illness on the victims of human rights violations and oppression. A meeting convened in the late 1990s by the American Red Cross to consider appropriate means of response revealed disparate factions with strong ideological and methodological positions. A number of groups attending noted “a lack of consensus on goals, strategies and impacts”.

Forging a consensus

As a result, in 2000 Carolyn Makinson brought together a number of leading international NGOs working in this area with academic groups from institutions that had engaged with emerging approaches into a Psychosocial Working Group to develop a shared framing of the field.[4] The group proposed that psychosocial interventions should be defined by an interest in human capital (notably in relation to the impact of mental ill-health on individual well-being), in social ecology (the relationships and broader social fabric disrupted by forced migration), and in culture and values (especially the erosion of rights and cultural norms). The interaction between these three domains was also emphasised. The core challenge of planning appropriate interventions arose in negotiating the provision of supports in these domains for an affected community in a manner that reflected genuine partnership rather than neo-colonial imposition. In presentations to local actors in-country, it was always discussion of this last issue that received the greatest attention.

Subsequently, two members of this working group, Mark Van Ommeren and Mike Wessells, were invited to co-chair an Inter-Agency Standing Committee (IASC) process for the development of what became the IASC Guidelines on Mental Health and Psychosocial Support in Emergency Settings. This initiative steered a process which focused on practical implementation rather than theory, and on wide local and national consultation in order to address the concerns about imposition that had marked the preceding decade. The guidelines, published in 2007,[5] succeeded in providing a framework that both integrated diverse disciplinary perspectives and was transparently accessible to diverse actors, local and international. In doing so, it accommodated major tensions within the field that had undermined coherence and collaboration since its inception.

A maturing, evidence-based field

The guidelines were substantially based on emerging best practice, although it was recognised that the evidence base supporting them was comparatively weak. While the subsequent formulation of supplementary guidelines for specific situations, such as the Ebola outbreak, were important, the most significant development in subsequent years has been gathering this much more robust evidence base. This included a major research agenda-setting exercise by Wietse Tol and colleagues[6] that identified a number of priority questions related to modalities of intervention; these were family- and school-based approaches, assessment methods, and indicators for monitoring and evaluation. Other questions related to identifying stressors, problems and protective factors from the perspective of affected populations, sociocultural adaptation of interventions, and whether interventions address locally perceived needs. The team facilitating this consensus exercise observed that the agenda emphasised “the generation of practical knowledge that could translate to immediate tangible benefits for programming in humanitarian settings, rather than addressing the key debates that have dominated the academic literature”. While this may be true, these two clusters of research questions show some resonance with a core tension within the MHPSS framing: the former emphasising the identification of effective and generalisable programme interventions, measures and indicators, with the latter emphasising the need for contextualisation.

With sustained support for research studies in the area through programmes such as Elrha’s R2HC programme,[7] MHPSS moved from being one of the poorest supported areas of humanitarian action in terms of evidence to one of the best. Much of the work has focused on documenting the impact of specific intervention approaches that are currently implemented at scale, such as structured activities within Child Friendly Spaces, or that are potentially scalable, such as Programme Management Plus (PM+). This work has contributed significantly to the goal of identifying impactful programmatic approaches, but also often points to the importance of the goal of accommodating the diversity of contexts to which such interventions need to be adapted. The field has thus matured to the point where the focus is on refining and strengthening proven interventions, or finding more effective or efficient modalities for their delivery.

Creative tensions

If, from the turbulence of the 1990s, the field formed in the 2000s and matured in the 2010s, what prospect is there for the field in the next decade? On the research side, there is a new research agenda-setting exercise underway with support from a number of donor agencies and intergovernmental organisations, reflecting the place that MHPSS has secured in humanitarian strategy. This is a consensus-building exercise engaging with diverse national and international stakeholders, whose outcome will not be known until well into 2021. However, there are at least three issues that seem likely to emerge from the exercise, and that will continue to engage practitioners and researchers alike in the next decade.

Scaling, fidelity and contextual adaptation: The challenge of balancing the development of generalisable, effective interventions with the need for cultural adaptation and sensitivity to the agendas of local actors will remain a key feature, if not the key feature, of work for some time to come. This is a significant task, reflecting the recurrent MHPSS challenge of combining technical generalisability with contextual understanding and engagement, and scaling interventions for access by a much greater proportion of affected communities while retaining fidelity to the active components of proven interventions. However, there are some very promising recent examples of contextual adaptation being considered as a task to be undertaken as a step-by-step process rather than as a vaguely stated ambition.

Relieving suffering or driving long-term change: Evaluations that have looked at longer-term impacts of psychosocial interventions have frequently found no major benefits for those in the programmes compared with those not receiving interventions.[8] Typically, this finding is not the result of a ‘drop off’ in the well-being of those who have attended programming but is rather the result of those who did not attend programming managing to ‘catch up’ in terms of adjustment. Despite short-term benefits being noted, the intervention is sometimes reported as having no impact. This raises the issue of whether psychosocial programming should be aimed principally at the relief of suffering or at shaping longer-term trajectories of adjustment. Promises of longer-term benefit may reflect an undue capture by a longer-term resilience narrative rather than a relief of suffering narrative. I believe that the positioning of psychosocial interventions as supporting populations in distress rather than demonstrating long-term benefits may be usefully established as the baseline expectation for the field. This is not to say that long-term benefits cannot be secured but it may be appropriate for psychosocial interventions to be judged in the same way that food, shelter and most health interventions are primarily judged – that is, on their amelioration of the suffering and risk in affected populations during an emergency, rather than on long-term trajectories of food security, settlement or physical well-being.

Focused intervention versus strategy of engagement: Finally, I anticipate debates continuing about the relative priority of focused MHPSS intervention programmes – such as tackling severe mental distress and the consequences of gender-based violence – and broader-focused community engagement strategies promoting agency, ownership and peace-building. We can anticipate, however, the development of clearer framing and theories of change linking these different forms of work. The breadth of influences on well-being reflected in community-based approaches was acknowledged in Kraus’s initial use of the term to describe the forces shaping the experience of the resettling refugee and in much literature since; the value of focused, targeted interventions addressing psychological and emotional distress is now also endorsed by a rich literature.

 

Alastair Ager aager@qmu.ac.uk @AlastairAger

Institute for Global Health and Development, Queen Margaret University; Mailman School of Public Health, Columbia University

 

[1] Kraus H (1939) ‘Starting Life Anew in a Strange Country’, The Annals of the American Academy of Political and Social Science, Vol 203 www.jstor.org/stable/1021890

[2] Ager A (1993) ‘Mental health in refugee populations: A review’,  Refugee Studies Programme, University of Oxford, for Project on International Mental and Behavioral Health, Harvard. http://fmo.bodleian.ox.ac.uk:8080/fedora/get/fmo:1082/PDF

[3] Ager A (1997) ‘Tensions in the psychosocial discourse: implications for the planning of interventions with war-affected populations’, Development in Practice 7 (4) www.jstor.org/stable/4029006?seq=1

[4] Psychosocial Working Group (2002) Psychosocial Intervention in Complex Emergencies: a Conceptual Framework
https://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.124.9995&rep=rep1&type=pdf

[5] IASC (2007) IASC Guidelines on Mental Health and Psychosocial Support in Emergency Settings
https://interagencystandingcommittee.org/system/files/2020-11/IASC%20Guidelines%20on%20Mental%20Health%20and%20Psychosocial%20Support%20in%20Emergency%20Settings%20%28English%29.pdf

[6] Tol W et al (2011) ‘Research Priorities for Mental Health and Psychosocial Support in Humanitarian Settings’ PLoS Med 8(9): e1001096 doi.org/10.1371/journal.pmed.1001096

[7] Tol W et al (2020) ‘Improving mental health and psychosocial wellbeing in humanitarian settings: reflections on research funded through R2HC’, Conflict and Health 14
https://conflictandhealth.biomedcentral.com/articles/10.1186/s13031-020-00317-6

[8] Panter-Brick C, Dajani R, Eggerman M, Hermosilla S, Sancilio A and Ager A (2017) ‘Insecurity, distress and mental health: experimental and randomized controlled trials of a psychosocial intervention for youth affected by the Syrian crisis, Journal of Child Psychology and Psychiatry 59 https://doi.org/10.1111/jcpp.12832

 

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