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Inter-Agency Standing Committee (IASC) Guidance on Mental Health and

Psychosocial Support in Emergency Settings

Inter-Agency Standing Committee (IASC) Guidance on Mental Health and

Psychosocial Support in Emergency Settings

Mark van OmmerenMental Health and Substance AbuseMSD/WHO, Genevavanommerenm@who.int

28 November 2006Public Health Pre-Deployment Training Chavannes de Bogis, Switzerland

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ASSISTANCE IN COMPLEX EMERGENCIES (eg DARFUR)

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ASSISTANCE IN NATURAL DISASTERS

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Principles and strategies for public mental health action

during and afteremergencies (WHO, 2003)

Consistent with

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Sphere Handbook (2004): First-time inclusion of a mental and social aspects of health standard

Covers: 8 social interventions4 psychological/psychiatric interventions

Consistent with

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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.

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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

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BEFORE DISASTER:

12-month prevalence

AFTER DISASTER:

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)

10%

20%

(reduces to 15% with natural recovery)

Moderate or severe

psychological / social distress

(no disorder)

No estimate

Large percentage

(reduces to unknown extent due to natural

recovery)

None or mild psychological /

social distress, which may

resolve over time

No estimate Small percentage

(increases over time due to natural recovery)

Summary Table of Generic WHO Projections

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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

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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

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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

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Controversial?

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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

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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

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IASC Task Force: 27 agencies - 1 year mandate

• IRC

• MdM-E

• Mercy Corps

• MSF-H

• Oxfam GB

• RET

• SC-UK

• SC-USA

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)

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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.

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Collaborative, multisectoral approach

• No single organization or community is expected to be able to conduct all actions covered in the guidance.

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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

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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

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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)

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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

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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

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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

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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

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Agenda settingNow 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

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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

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Post-emergency: address long-term increase in

mental disorders

Formal health sector response:

1. update MH policy and legislation

2. develop sustainable community mental health (MH) services

3. organize MH care in primary health care

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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)

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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