Mental health and psychosocial support: hidden potential and harm

Towards understanding the unintended and intended social effects of mental health and psychosocial support interventions

In October 2019, Dutch Minister for Foreign Trade and Development Cooperation, Sigrid Kaag, organised the International Conference on Mental Health and Psychosocial Support in Crisis Situations. Together with a coalition of 28 countries and ten organisations, she signed the Amsterdam Conference Declaration, which pledges a commitment to ‘look for opportunities to draw attention to mental health and psychosocial needs of people affected by emergencies’ and ‘to integrate and seek opportunities to further scale up mental health and psychosocial support’.[1] This pledge resulted from the growing attention for large unmet mental health needs among people affected by disaster and conflict. Although estimated rates of mental disorder after conflict vary between contexts, a meta-analysis of ‘methodologically stronger’ surveys displays average prevalence rates of 15-20% for depression and post-traumatic stress disorder.[2] In contrast, only 0.3% of all development assistance for health was dedicated to mental health between 2006 and 2016.[3]

At the conference, an important call for action was made to increase the available budget for mental health and psychosocial support (MHPSS). MHPSS is the catch-all term for various interventions addressing mental health needs, ranging from psychotherapy to music lessons. Policy makers and practitioners increasingly consider MHPSS to be a crucial element of humanitarian aid. They further expect MHPSS to have positive effects on political and socioeconomic goals such as ‘poverty reduction, peacebuilding, addressing gender-based violence and [the] reconstruction of affected areas and economies’.[4] This article argues that the pledged commitment and call for more funding should go hand-in-hand with an increased investment in (academic) knowledge production on the functioning of MHPSS, as we currently lack a comprehensive understanding of these interventions, and in particular of their positive (potential) and negative (harmful) longer-term effects.

Uncovering unintended effects

Both practitioners and academics have warned of the possible unintentional harm MHPSS interventions may cause to their recipients.[5] Following Shah, harm can be a direct consequence of MHPSS interventions not being designed in a culturally appropriate manner, resulting in several negative consequences such as harm to psychological wellbeing and erosion of community’s trust in MHPSS.[6] For example, he described the case of combatants in Sub-Saharan Africa for whom conventional therapy would increase distress, as they believe talking about the people they killed invites angry spirits.[6] Adverse effects may also follow from the interplay between context and intervention, when sources of stress are left unaddressed and interventions subsequently run the risk of being negatively experienced as ‘irrelevant or imposed’.[7] According to Miller and Rasmussen, available data suggests that ‘daily stressors’ (social and material conditions such as poverty, family violence, unsafe housing, and social isolation) cause mental health problems, and therefore should be a priority in MHPSS.[8] If focus is limited to individual psychological trauma resulting from conflict or other humanitarian emergencies, the collective experience is overlooked and people’s capacity to recover is not strengthened.[7] Avoiding harm is a central point of attention within the internationally recognised IASC Guidelines on mental health and psychosocial support in emergency settings, which state that ‘the potential for causing harm as an unintended, but nonetheless real, consequence must be considered and weighed from the outset’ in all humanitarian interventions.[9]

Evaluations of interventions in the field of international cooperation, however, often fail to analyse unintended effects, and are therefore in need of more appropriate methodologies, as addressed by Koch and Schulpen in the article Introduction to the special issue ‘unintended effects of international cooperation’.[10] Most evaluations exclusively focus on intended objectives and have a short-term design, thereby neglecting unintended effects, especially those which may only arise after a longer period of time. While the intended direct effects of MHPSS interventions have been rigorously assessed by randomised control trials (RCTs), this method is known for its risk of overlooking unanticipated outcomes.[11] Yet, analysing unintended effects is necessary to be able to plan the most adequate interventions and to mitigate the risk of doing harm. Unintended effects can thus be negative, causing harm, but they can also be positive, creating additional, unexpected benefits, or even neutral.[12] Positive unintended effects are particularly underrepresented in the literature,[10] which makes it more difficult to capitalise on them. So there are lessons to be learned that can help further improve MHPSS.

What are the knowledge gaps?

Our research team from Radboud University conducted a literature search between 1 July 2020 and 20 September 2020 to get a first impression of which unintended effects of MHPSS interventions have been described in academic literature between 2011 and 2019.[13] Based on the reference lists of seven recently published systematic reviews on MHPSS interventions in man-made and natural humanitarian emergency settings, our search revealed that only twelve out of the 134 studies reported unintended effects. Out of these twelve studies, eleven described an unanticipated negative change in symptoms related to mental health, and only one study reported a social unintended effect. The studies included in our literature search had a strong focus on direct and intended effects, namely the possible improvement of mental health. These findings suggest that unintended effects, which transcend the psychological and individual, are being overlooked. The twelve unintended effects described above were all found in quantitative studies, which is likely related to the fact that most studies in the reference lists were quantitative (111 out of 134). Adding a qualitative component may help detect other types of unintended effects, through inductive analysis of MHPSS interventions.[11]

Furthermore, Blanchet et al. have shown in their systematic review that most of the attention is aimed at psychological interventions, and that the evidence-base of psychosocial interventions is weaker, although this type of intervention is most commonly practised.[14] Since many of the claims made to spur investments in MHPSS point to the social outcomes of these psychosocial interventions, it is pivotal to research if these are true.

Finally, the evaluations of the included studies all considered short-term effects only, and were conducted between two weeks and eight months after the intervention took place. In this regard, we lack knowledge about the long-term (socioeconomic) impact of MHPSS interventions for displaced persons and the larger community.

Ways forward

A new research approach is required to reach a comprehensive understanding of the unintended and intended social effects of MHPSS. First, in order to make claims about these effects, it is essential to follow participants in MHPSS interventions over a longer period of time. A longitudinal and mixed-method research design will allow us to come to a more encompassing understanding of the (unintended) consequences for people who have participated in a MHPSS intervention, such as expanding a social network or finding a job. Studying these long-term and social effects requires a multi-disciplinary approach combining insights from psychology, anthropology and sociology.

Second, participants in MHPSS are often forcibly displaced as a result of humanitarian crises. They therefore move between places, and some may resettle to a new country. Research should thus be carried out in multiple geographical contexts to follow people who have participated in (perhaps multiple) MHPSS interventions. This will allow us to investigate the extent to which effects depend on contextual factors (e.g. the living conditions of a host country), and to analyse if MHPSS has effects on migration trajectories and integration.

Third, special attention should be given to psychosocial and multidomain interventions. These interventions target mental health and social life domains simultaneously, such as safety and education at the family or community level. The evidence base is currently weaker for these interventions compared to psychological interventions. Psychosocial and multidomain interventions do however offer a possible pathway to overcome the negative effects of overlooking structural problems and capitalise on positive effects of mental health improvement. Together, these three steps form the basis of our research team’s new approach, and can contribute to understanding MHPSS more comprehensively.

Conclusion

There is a need to deepen our understanding of the intended and unintended social effects of MHPSS interventions. This requires a long-term, multi-disciplinary approach, carried out in multiple contexts and preferably focusing on psychosocial and multi-domain interventions. Insights gained can contribute to an advanced, more encompassing evaluation framework. Now is the right time to jump on the bandwagon, as MHPSS is receiving increased attention and funding. There is great hidden potential in MHPSS to heal, but also to do harm. This is why its effects, both intended and unintended, positive and negative, deserve a more critical evaluation, and this requires investment from the academic and policy community.

Background information

The literature search was conducted by Vy Trân Nhât between 1 July 2020 and 20 September 2020. The seven systematic reviews of MHPSS interventions which were searched, are recently published, between 2011 and 2019, and focus on studies in man-made and natural humanitarian emergency settings. To filter the studies in the seven reference lists, the following eligibility criteria were used: studies published after and including 1980, studies published in English, both quantitative and qualitative studies, both man-made and natural humanitarian emergency settings, all types of MHPSS interventions, interventions targeting both adults and/or children and young people (CYP). 137 studies from the reference lists were found eligible, however, two studies were different samples presented in a separate third study, and one PhD dissertation was not accessible. 134 studies were therefore ultimately included. Titles, abstracts and texts were scanned on the basis of a number of search terms (see table).

Studies which did not describe unintended effects and did not have any relevant keyword hits were excluded, leaving 23 studies. After reading the remaining articles in detail, the studies which only reported a lack of intended effects were excluded. In the end, twelve studies were found to report unintended effects. The seven systematic reviews and twelve included studies are available at request.

References

Blanchet K, Ramesh A, Frison S, Warren E, Hossain M, Smith J, et al. Evidence on public health interventions in humanitarian crises. The Lancet. 2017;390(10109):2287-96. doi:10.1016/S0140-6736(16)30768-1.

Ministry of Foreign Affairs. Declaration: mind the mind now [Internet]. Amsterdam: Government of the Netherlands; 2019 [updated 2019 Oct 8; cited 2020 Oct 9]. 5 p. Available from: https://www.government.nl/documents/diplomatic-statements/2019/10/08/amsterdam-conference-declaration

Ventevogel P, Van Ommeren M, Schilperoord M, et al. Improving mental health care in humanitarian emergencies. Bull World Health Organ. 2015 Oct 1;93(10):666-A. DOI: 10.2471/BLT.15.156919

Liese BH, Gribble RSF, Wickremsinhe MN. International funding for mental health: a review of the last decade. Int Health. 2019;11(5):361-9. DOI: 10.1093/inthealth/ihz040

Government of the Netherlands [Internet]. Why is it important to integrate MHPSS into humanitarian response? [Internet]. Government of the Netherlands; 2019 [date unknown; cited 2020 Oct 9]. Available from: https://www.government.nl/topics/mhpss/integration-of-mental-health-and-psychosocial-support-in-humanitarian-response/why-is-it-important-to-integrate-mhpss-into-humanitarian-response

Wessells MG. Do no harm: Toward contextually appropriate psychosocial support in international emergencies. Am Psychol. 2009 Nov;64(8):842-54. DOI: 10.1037/0003-066X.64.8.842

Shah SA. Ethical standards for transnational mental health and psychosocial support (MHPSS): do no harm, preventing cross-cultural errors and inviting pushback. Clinical Social Work Journal. 2012;40(4):438-49. DOI: 10.1007/s10615-011-0348-z.

Miller KE, Rasmussen A. War exposure, daily stressors, and mental health in conflict and post-conflict settings: Bridging the divide between trauma-focused and psychosocial frameworks. Soc Sci Med. 2010;70(1):7-16. DOI: 10.1016/j.socscimed.2009.09.029

Summerfield D. A critique of seven assumptions behind psychological trauma programmes in war-affected areas. Soc Sci Med. 1999 May;48(10):1449-62. DOI: 10.1016/S0277-9536(98)00450-X

Inter-Agency Standing Committee. IASC Guidelines on Mental Health and Psychosocial Support in Emergency Settings [Internet]. Geneva: IASC; 2007 [date unknown; cited 2020 Oct 10]. 205 p. Available from: https://www.who.int/mental_health/emergencies/9781424334445/en/

Koch D-J, Schulpen L. Introduction to the special issue ‘unintended effects of international cooperation’. Eval Program Plann. 2018 Jun;68:202-9. DOI: 10.1016/j.evalprogplan.2017.10.006.

Bamberger M, Tarsilla M, Hesse-Biber S. Why so many “rigorous” evaluations fail to identify unintended consequences of development programs: how mixed methods can contribute. Eval Program Plann. 2016 Apr;55:155-62. DOI: 10.1016/j.evalprogplan.2016.01.001.

Jabeen S. Do we really care about unintended outcomes? An analysis of evaluation theory and practice. Eval Program Plann. 2016 Apr;55:144-54. DOI: 10.1016/j.evalprogplan.2015.12.010.