Inter-Agency Standing Committee (IASC) Guidance on Mental Health and Psychosocial Support in Emergency Settings

1. Inter-Agency Standing Committee (IASC) Guidance on Mental Health and Psychosocial Support in Emergency Settings Mark van Ommeren Mental Health and Substance Abuse MSD/WHO, Geneva vanommerenm@who.int 28 November 2006 Public Health Pre-Deployment Training Chavannes de Bogis, Switzerland

2. ASSISTANCE IN COMPLEX EMERGENCIES (eg DARFUR)

3. ASSISTANCE IN NATURAL DISASTERS

4. Principles and strategies for public mental health action during and afteremergencies (WHO, 2003) Consistent with

5. Consistent with Sphere Handbook (2004): First-time inclusion of a mental and social aspects of health standardCovers: 8 social interventions4 psychological/psychiatric interventions

6. Mental health and psychosocial support covers . . . any type of local or outside support that aims to (a) protect or promote psychosocial well-being and/or (b) prevent or treat mental disorder.

7. Diverse needs in midst of emergencies • pre-existing social problems • E.g. marginalized groups • disaster-induced social problems • E.g. destruction of protective community's structures • pre-existing mental disorders • E.g. chronic psychosis • disaster-induced distress and disorder • E.g. normal fear (past, present, future), mood and anxiety disorders (incl. PTSD) • humanitarian aid-induced problems • E.g. undermining of traditional supports

8. Summary Table of Generic WHO Projections

9. Why inter-agency guidance? • Enough consensus on good practices • Transcend ideological debates and dogma • Reduce inappropriate practices • Less chaos: facilitate coordinated response on priority issues

10. Controversies (of the past?) • Dogma (e.g. 'trauma' vs 'no trauma', 'psychosocial' vs 'mental health') • Duplicate assessments • Parachuting foreign clinicians • Exclusive focus on intra-psychic processes, clinical interventions • Training without proper follow-up supervision

11. Controversies (of the past?) (cont'd) • Ignoring/over-focus on PTSD or pre-existing severe mental illness • Neglecting people's participation • Neglecting informing affected populations • Neglecting social action • Ignoring psychosocial factors in education, health, nutrition, watsan and shelter programming

12. Controversial?

13. IASC Task Force Guidance • Forthcoming Dec 2006 • Modelled after IASC HIV/AIDS & GBV guidance • Focus on minimum response • Focus on practical actions • Matrix outlining key interventions / supports • Short action sheets on each key intervention written by experts of those agencies specialized in the topic

14. Inter-Agency Standing Committee (IASC) Committee of heads of large humanitarian agencies responsible for global humanitarian policy (see UN General Assembly Resolution 48/57) • 10 UN agencies (e.g. OCHA, UNFPA, UNHCR, UNICEF,, WFP, UNICEF, WHO) • Red Cross movement (IFRC and ICRC) • 3 large NGO consortia (InterAction, ICVA, SCHR) covering 100s of INGOs. • IOM • World Bank

15. IRC MdM-E Mercy Corps MSF-H Oxfam GB RET SC-UK SC-USA IASC Task Force: 27 agencies - 1 year mandate IASC bodies • ICVA • IFRC • Interaction • IOM • OCHA • UNFPA • UNHCR • UNICEF • WFP • WHO Individual INGOs: • ACF • Am. Red Cross • Action Aid Int. • CARE Austria • CCF • HealthNet-TPO • IMC • ICMC • INEE UN-NGO co-chaired (WHO & InterAction)

16. Not a cookbook! • Local situation analyses are essential • To determine what specific actions are priority in the local context • To avoid social/cultural inappropriate action. • These guidelines do NOT give implementation details but rather a list of summary actions.

17. Collaborative, multisectoral approach • No single organization or community is expected to be able to conduct all actions covered in the guidance.

18. Role of mental health professionals? • Use their position for advocacy with other sectors to ensure that key risk factors for impaired mental health and psychosocial well-being are being addressed across sectors. • Supervision in implementing aspects of guidance on clinical/interpersonal forms of psychological/psychiatric support

19. Document structure • Chapter 1: Pre-amble (6 pages) • Chapter 2: Matrix covering 25 minimum response interventions (7 pages) • Chapter 3: 25 action sheets (approx. 4 pages each) (total 104 pages) Total: doc of approx 115 pages + matrix poster + CD-ROM

20. See handout • What could be WHO and recommended Health Cluster activities in emergencies are highlighted in blue • Core interventions include • Coordination and assessment • Training health professionals in basic support • Care and protection of people with severe disorders (e.g. esp. if in institutions)

21. Coordination is Key • The guidelines emphasize the importance of multi-sectoral coordinated action and community involvement. • Too often split coordination groups • One action sheet on intersectoral coordination: • Each Action Sheet includes links to related Action Sheets for related actions • Matrix to be used as coordination tool

22. Several 'firsts' • First guidance to cover MH support from to bottom of 'pyramid' in emergencies (E) • First guidance on mental health coordination in E • First guidance on sub abuse in E • First guidance on 'self-care' materials in E • First (?) guidance on interface with healers • Matrix provides model on how to work on mental health with agencies outside health sector

23. Early successes • Mostly positive reviews (150+ reviewers from academia, IASC bodies, UN, INGOs, HQ & field-based colleagues, major professional associations, small NGOs, from all continents) • Drawing in not only English but also French and Spanish speaking colleagues • Early implementation already happening • Matrix used as a coordination tool (Java) • Core tool for training of all Am Red Cross staff in Asia • Tool for international Red Cross/Crescent consultants • It has become the de facto framework of various agencies

24. Early successes (cont'd) • Spontaneous translations (Hindi, Bahasa, Tamil, Sinhala, Arabic) • Spontaneous NGO review workshop in Sri Lanka (positive review!) • Spontaneous regional workshops in W-Africa • Used for needs assessment in Jaffna • Used for attention to custodial hospitals in Lebanon and Jaffna • Radically improved relationships and collaboration among agencies at HQ-level

25. Agenda setting Now increasingly accepted by agencies outside health sector • Health sector does have a legitimate leadership role • Custodial hospital on the agenda in emergencies • Severe mental disorders on the agenda in emergencies • Sub abuse on the agenda (somewhat) in emergencies Now increasingly accepted by health sector • Social approaches are not all 'smoke' • Sharing coordination has many advantages • Value of participatory approaches/ community mobilization

26. Where is the evidence? • Much more evidence needed for psychological interventions in real word emergency settings → Challenge: deciding on outcome measure • Much evidence from qualitative social science (anthropology, sociology) in support of Sphere social interventions in real word emergency settings (Batniji et al 2006) → Challenge: collecting quantitative evidence for social interventions

27. Post-emergency: address long-term increase in mental disorders Formal health sector response: • update MH policy and legislation • develop sustainable community mental health (MH) services • organize MH care in primary health care

28. Self-care for staff after critical incident exposure • Before: Enhance resilience (improve work and living environment, stress management) • After: 100% of people: access to psychological first aid + useful self-care materials • Single session psychological debriefing is ineffective • If not able to function or if suffering intolerable, immediate referral to mental health professional trained in managing of acute problem (few %) • 100% systematic follow-up (1-3 months)

29. Key messages • Be aware of own and other's dogma • Use the increasing expert consensus / inter-agency consensus on what is good mental health and psychosocial support • Consider using forthcoming IASC guidance • Strive towards integrated, multi-sectoral response • Think about long-term clinical and health system development needs • Take care of yourself