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Courtesy: WHO (2011) Psychological first aid: Guide for field workers

Seven Key Actions for Disaster Mental Health & Psychosocial Support

This post proposes key actions that could be implemented by disaster management authorities in Sri Lanka to mitigate the mental health and psychosocial impacts of future crisis events.

Although the field of Mental Health & Psychosocial Support (MHPSS) has developed considerably in Sri Lanka since the late 1980s (Galappatti, 2003, Somasundaram, 2014), there still remains a lack of detailed National policy and protocols for MHPSS actions in response to crisis events. Ten years after the Indian Ocean Tsunami and six years after the end of Sri Lanka’s civil war, there is an urgent need to consolidate and institutionalize learning from both local experience and global best practice. Below are proposed minimal key actions in seven areas of intervention that could form the core of state and non-government MHPSS responses within a broader framework of Disaster Risk Reduction.

A Very Brief History of the MHPSS Field’s Evolution

Mental health and psychosocial support in the context of disasters and conflict is a relatively young field. Although there was limited acknowledgement of the effects of war experiences on combatants as far back as the 17th century, it was only in the 1980s that there was a significant recognition of the mental health impacts of disaster and conflict on civilians. This was initially limited to a focus on mental disorders, especially the diagnosis of Post-Traumatic Stress Disorder, with the response typically being medical and psychological treatments offered by mental health workers. By the mid-1990s, this view was expanded to also acknowledge the social impacts of crisis events on family & community, leading to the development of community-based social interventions to address these. There was also a growing recognition of the close relationship between the psychological and social dimensions, which was reflected in the use of the term ‘psychosocial’. In landmark 2007 guidelines published by the Inter-Agency Standing Committee, which comprises the key UN and non-UN humanitarian actors globally, the composite term Mental Health and Psychosocial Support (MHPSS) was first adopted to “describe any type of local or outside support that aims to protect or promote psychosocial well-being and/or prevent or treat mental disorder.”

The IASC MHPSS Guidelines provided support for a wide spectrum of interventions to support individuals, families and communities affected by humanitarian emergencies, and provided guidance for how these should be organized. The Guidelines’ ‘Intervention Pyramid’ illustrated how multiple levels of support were needed, with more general efforts to protect and promotion mental health and psychosocial wellbeing located in the lower levels of the pyramid (representing the majority of the affected population), and more specialised interventions that sought to address more targeted or complex issues located in the higher levels (indicating a smaller sub-set of the population).

IASC MHPSS Guidelines ‘Pyramid’ (2007)

Developments in the field in Sri Lanka have largely followed similar trends to the global field (Galappatti, 2003; 2014), and there has been a growing body of published and grey literature over a couple of decades that has documented this work (see archive being developed on www.mhpss.net).

Seven Proposed Key Actions

The actions elaborated below are offered as a minimal or basic approach to organizing and directing state, non-government and other actors in Sri Lanka who may play a role in protecting, promoting and restoring mental health and psychosocial wellbeing in relation to crisis events.

  1. PFA for frontline responders;
  2. Practical Actions for Relief Work;
  3. Information Sharing and Communication;
  4. Non-specialised MHPSS;
  5. Specialist MHPSS;
  6. Coordination;
  7. Prevention and Promotion through Preparedness and Mitigation

Psychological First Aid

Psychological First Aid (PFA) is the current recommended evidence-supported first MHPSS response that may be provided by persons who are not specialists in mental health (IASC, 2007; WHO, 2011). Its aim is to provide humane, supportive and practical assistance to persons in distress in order to reduce of distress, mitigate lasting impacts & refer highly vulnerable persons. A basic orientation in PFA can be delivered in 4–8 hours and training content has been designed for use with lay persons and adaptation to a wide range of socio-cultural contexts.

The 2011 WHO manual on PFA has already been adapted and translated into Sinhala (2013) and Tamil (2013), and piloting of this material through over 90 trainings with a wide range of participants in Sri Lanka indicates a high degree of acceptability and relevance of these materials.

It is proposed that key Disaster Management Centre (DMC) and Mental Health / Public Health staff (ie. Medical Officer for Health, Medical Officer for Mental Health) at District or sub-District level are trained as PFA trainers with a standardized training package to be delivered both to first responders and community members as a part of disaster preparedness and response activities.

Practical Actions in Relief Work

Both international guidelines (IASC, 2007, Sphere, 2011) and Sri Lankan practice (Galappatti, 2003; 2014) have recognized that wider relief efforts and humanitarian actions may have significant positive and negative impacts on the mental health and psychosocial wellbeing of affected people. Therefore, there has been an emphasis on attention to the principle of ‘Do No Harm’ and on addressing practical needs in ways that maintain dignity, enable self-efficacy through people’s full participation in their own care and recovery, and mitigate key stressors that can threaten wellbeing.

In Sri Lanka, there have been positive experiences of engagement across a range of sectors such as Water and Sanitation, Shelter, Education, Livelihoods or Nutrition to include practices and approaches that protect and promote mental health and psychosocial wellbeing. Notable examples have included the following: Establishment of safe toilets & bathing spaces for women and children; Supportive processes for identification of missing / dead after the tsunami; Provision of information about relief, shelter and other services; Involvement of displaced persons in management of food preparation and distribution; Prioritizing the resumption of education and special measures to delay exams immediately after the tsunami; Ensuring camp management is inclusive and perceived as fair; Prevention of chaotic relief distribution; Reuniting family members, especially children; Supporting people to resume religious practices or conduct rituals that are meaningful to them; Enabling communities to organise themselves as family groups or other collectives to address priority issues.

It is proposed that there is an adaptation (and translation) of existing guidelines for Sri Lanka and provision of a brief training package for key responders on how to implement relief, reconstruction & resettlement in ways that protect and promote mental health and psychosocial wellbeing.

Information Sharing and Communication

It is worth paying special attention to the issue of communication and information exchange with affected people, as the reliability and quality of this will impact their ability to access services, to make their own decisions and arrangements to respond to their circumstances, and also to shape the activities of those who seek to assist them.

Provision of accurate, useful and trusted information to affected communities can help reduce psychological stress and social conflict, and should be used as a preventative measure. This information may pertain to crisis events themselves (ie. what is a tsunami, how likely is it to happen again) or to services and entitlements (ie. how long will this shelter be available, what is the basic ration allowance, how will the compensation system be implemented). Honest communication about issues about which there is no certain information, but which may be important to affected people is also vital (ie. when will it be safe to go back home).

The ability for affected people to communicate meaningfully with the authorities and agencies that are seeking to assist them, can have benefits for their sense of self-efficacy in difficult circumstances, which is a protective factor for mental health and psychosocial wellbeing.

It is proposed that key communications strategies /protocols be established for effective information exchange with affected persons in camp and non-camp based settings, with an emphasis on addressing key concerns of the population and vulnerable groups.

Non-Specialist MHPSS

Some individuals or groups may require more focussed interventions than the promotive or protective activities that are undertaken for the population as a whole. For example, children who are orphaned or separated from their caregivers will need specific care arrangements and support. Likewise, survivors of gender-based violence often require appropriate emotional support as well as counselling, practical, legal or economic assistance. The needs of individuals or groups that are identified as particularly vulnerable or requiring additional support should be addressed through existing mechanisms ((ie. education, health, social services, community-based groups, etc) where appropriate.

Whilst highly trained personnel may not be necessary to deliver such interventions, it is important that the individuals and institutions that provide these have effective approaches, required skills and robust implementation systems — as well as capacity to facilitate referral where clients require more specialized care.

It is proposed that there is mapping of key service providers and their capacities at divisional secretariat and district level, in order to determine capability to respond to common post-crisis issues that require focused intervention. This should then inform the development of relevant skills training packages and services to meet the gaps identified. Information from this mapping exercise (which should be rapidly verified/updated after a crisis event occurs) should be integrated into referral mechanisms to be used during the crisis response.

Specialized MHPSS

People with acute mental health needs (including persons attempting suicide or engaging in highly risky behaviour) may require specialized care. Similarly persons with complex social problems may also require assistance from especially skilled personnel. Although typically such problems affect a relatively small proportion of the affected population, the seriousness of these issues does call for the intensive use of specialised (and costly) human resources.

In the context of Sri Lanka, where specialised practitioners in MHPSS are relatively few in number and also often play a key role in technical leadership and management of wider MHPSS services, the optimal use of these limited human resources must be carefully balanced— in order to ensure that both important roles are carried out. In such a situation, the distinction between non-specialized and specialized MHPSS services may become apparent, with many tasks shifted to non-specialists whilst more specialized practitioners play a close supervisory or backstopping role.

It is proposed that key individual practitioners and institutions able to provide specialized care are mapped at district level, in order to determine their capacity to respond to such needs. Measures must be taken to develop institutional and human resource capacity where there are significant gaps. Information from this mapping exercise (which should be rapidly verified/updated after a crisis event occurs) should be integrated into referral mechanisms to be used during the crisis response.

Coordination

The failure to coordinate the efforts of diverse service providers after a crisis event can undermine the MHPSS response and hinder affected persons’ from accessing appropriate and good quality support. Effective coordination will require the establishment of a mechanism for MHPSS responders from relevant sectors like health, education, social care / protection and others to work together on assessing needs, determining priorities, developing comprehensive intervention strategies and implementing services in ways that are complementary.

As coordination is most vital close to the ground, in Sri Lanka’s case this would likely take the form of a district level MHPSS coordination mechanism (which might be convened under the authority of the Government Agent/Disaster Management Centre, but would need to be guided by technical inputs from MHPSS specialists and key service providers). If needed (especially in the case of major disasters or crisis events), there would be a need for a national MHPSS coordination mechanism that incorporates representatives of local-level coordination mechanisms.

It is proposed that a template be developed for district-level MHPSS coordination mechanisms, which may be adapted to local needs and circumstances in the event of a crisis and integrated with broader disaster management structures. Training on the coordination of MHPSS responses should be provided for key DMC staff and other relevant government departments/ministries (ie. health, education, social welfare, child care, women’s affairs, etc) with a view to promoting well-informed, dynamic and responsive leadership for coordination efforts.

Protection and Promotion through Preparedness and Mitigation

Effective Disaster Risk Reduction activities can avoid and mitigate harm, thereby also preventing and reducing impacts on mental health and psychosocial wellbeing (Galappatti & Richardson, tbc). Participatory and inclusive DRR processes can promote a sense of safety, build capacity, strengthen interpersonal connections and enhance a feeling of self-efficacy that can bolster individual and collective resilience against negative mental health & psychosocial impacts in the event of a crisis event.

It is proposed that key DRR practices and processes for disaster prevention, mitigation and preparedness currently undertaken by relevant state authorities in Sri Lanka be reviewed for potential impact on promotion and protection of mental health and psychosocial wellbeing, with remedial measures or enhancements being designed and implemented where appropriate. Brief, effective training packages must be developed and delivered to key DMC personnel on how they can contribute to promotion and protection of mental health and psychosocial wellbeing through core DRR activities. This training can be combined with that proposed above in the section on how ‘Practical Actions in Relief Work’ can support recovery.

In Conclusion

Despite the considerable lessons learned in Sri Lanka over the past few decades of MHPSS response, as well as broad international consensus on best practice, the government of Sri Lanka has not yet defined specific policies or plans for protection, prevention and recovery of the mental health and psychosocial wellbeing of affected persons in the event of a crisis. As the current National Disaster Management Policy makes only a brief and general reference to ‘counselling’ activities, there is an urgent need to put in place a broad, practical framework that is informed by existing capacities and past experience. The seven key actions proposed above can be elaborated in greater detail, but are offered here in outline form as a potential starting point for a discussion about establishing such a framework to guide the work of state and other actors in relation to MHPSS in Disaster Risk Reduction.

References

Galappatti, A. (2003) “What is a Psychosocial Intervention? Mapping the Field in Sri Lanka”, Intervention: the International Journal of Mental Health, Psychosocial Work and Counselling in Areas of Armed Conflict, 1(3).

Galappatti, A. (2014) “Trauma and Beyond: The Evolving Field of Mental Health and Psychosocial Work in Sri Lanka” in Somasundaram, D., Scarred Communities: Psychosocial Impact of Man-made and Natural Disasters on Sri Lankan Society, Sage. See also here.

Galappatti, A & Richardson S. M. (tbc) “Disaster Risk Reduction as Protection and Promotion of Mental Health and Psychosocial Wellbeing: A View from Education in Emergencies”.

IASC (2007) The IASC Guidelines on Mental Health and Psychosocial Support in Emergency Settings, IASC.

Somasundaram, Daya (2014) Scarred Communities, Sage Publications

The Sphere Project (2011) Sphere Handbook: Humanitarian Charter and Minimum Standards in Humanitarian Response, The Sphere Project.

WHO (2011) Psychological first aid: Guide for field workers, World Health Organization.

WHO (2013) Sinhala Translation of “Psychological First Aid: A Field Guide”, The Good Practice Group.

WHO (2013) Tamil Translation of “Psychological First Aid: A Field Guide”, The Good Practice Group.

Ananda Galappatti is a medical anthropologist based in Sri Lanka. He is the Director of Strategy at The Good Practice Group, a Managing Board Member of mhpss.net and also a member of the editorial board of the journal Intervention.

Written by

Medical Anthropologist | Ashoka Fellow | Mental Health & Psychosocial Support Practitioner

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