Psychosocial support for disaster survivors

From IRIN, a story on addressing mental health of disaster survivors.

Psychosocial support (PSS) is about helping survivors of disasters or crisis resume their regular lives. It covers everything from individual counselling to re-opening schools.

IRIN asked people involved in psychosocial work at the UN Children's Fund (UNICEF), Médecins sans Frontières (MSF), the International Rescue Committee (IRC), Save the Children, Columbia University, and the Interagency Standing Committee Working Group on Mental Health and Psychosocial Support to describe what they do, how they determine progress, constraints to delivering this support, and how they measure their success.

"Psycho" and "social"

PSS has been polarized into two camps said Mike Wessells, a professor at Columbia University in the United States who chairs the Taskforce on Mental Health and Psychosocial Support in Emergencies of the Inter-Agency Standing Committee (IASC), a global body.

The 'psycho' approach based on clinical mental health seeks to address trauma, depression, and anxiety. A more holistic ‘social’ method tackles the problems people face in emergencies, like the threat of physical insecurity, displacement, not knowing the whereabouts of loved ones, loss of livelihood, and access to school.

Some NGOs, such as MSF, combine psycho and social. "Our main objective is to restore functioning on an individual or community level ... we try to unite the individual, community and environment perspectives," said MSF's mental health specialist in Amsterdam, Kaz de Jong.

The gap is slowly narrowing as perceptions change. "Mental health support cannot exist without the other forms of support – financial aid, health interventions – if you give people counselling and no livelihood help, it won't take hold," said PSS specialist and psychologist Mirella Papinutto, who has worked for UNICEF, the International Committee of the Red Cross (ICRC), and the Italian poverty alleviation NGO, COOPI.

NGOs often focus on the social side. "There is a general feeling that if we can provide recreation, education and community integration [for children], then some psychosocial issues that may later have developed, can be dealt with early on," Save the Children's child protection adviser, Christine McCormick, told IRIN. Children may also be referred to social workers or health authorities for counselling services.

What are PSS activities?

MSF provides one-on-one support to help people reconnect with their families, communities and friends after a traumatic event; trains local counsellors to continue the work when the agency leaves the area; teaches people to manage stress and distress; helps parents deal with traumatised children; counsels the survivors of gender-based violence.

UNICEF, IRC and Save the Children help re-open schools or support community schools, and train teachers and volunteers to offer emotional support to children.

"The behaviour of attending school every day and the establishment of a routine ... supports children's well-being ... [it] brings back a child's sense of identity, it allows them to interact with their peers, and process what they have gone through," said Deborah Haines, emergency education adviser at Save the Children.

"PSS is the port of entry," said Papinutto. "It's the system through which you ... follow up, with all referrals from medical to legal, social and economic; it is at the heart of everything."

How do crises affect people?

Examples range from loss of self-esteem, depression, relationship difficulties, the development of phobias or physical problems with psychological roots, to community rejection, said Papinutto. MSF's De Jong noted that mothers sometimes stop caring for their children; fathers can become frustrated and angry with their families as well as other people.

Specific groups have their own needs – children associated with armed forces can be stigmatized by their families and communities; they might feel they are spiritually contaminated by the people they have killed; they have fallen behind in their education or lacked schooling; they might be addicted to drugs; girls could have reproductive or sexual health problems, Papinutto said.

After the earthquake struck Haiti in January 2010, many schoolchildren were found to be withdrawn or aggressive, some isolated themselves, and some children had "invisible symptoms", said Haines.

Are there minimum standards?

Yes. The IASC guidelines on Mental Health and PSS in Emergencies were drawn up by some 27 partner agencies in humanitarian, clinical and social work, and published in 2007.

For the first time, they called for psychosocial support to be integrated into all humanitarian sectors, said Wessells. "When planning camp management, the guidelines ask: 'Is there enough privacy? Is attention paid to overcrowding? Are the latrines locked and well-lit? Is there a space where people can bury [dead] bodies?'"

The blueprint is a pyramid with four tiers: the first covers basic needs like shelter, safety, clean water and sanitation, healthcare and food. The second focuses on people who require community and family support to maintain their mental health and psychological wellbeing.

The third covers people who require mental health support from government services, or a combination of counseling and livelihoods support. The top tier represents the three to four percent of people whose intolerable suffering makes daily functioning difficult, and who require specialist psychiatric help.

Is PSS improving?

Practitioners say it is. "There was a more coordinated, systematic and holistic PSS response in Haiti, much improved since the Asian tsunami [in 2004]," said Sabine Rakotomalala, a psychosocial support provider for UNICEF and Terre des Hommes, a child rights organization. Wessells agreed.

MSF’s De Jong noted that "People from different agencies and different professions – social workers, camp planners, psychiatrists - sat around the table." PSS activities began five weeks after the earthquake.

Sue Dwyer, Vice-President of International Programmes at IRC, said sexual and gender-based violence programmes had attracted "a huge increase in funding ... It still remains insufficient in relation to the needs, but compared to 10 years ago, funding streams have significantly increased."

PSS has also been gaining respect. "Nowadays you see more and more mental health interventions ... and the social side of psychosocial is no longer overlooked," De Jong commented. "The field itself has evolved - in the 1980s you went for counselling when you had a serious disorder, nowadays they [mental health services] are everywhere."

Wessells said the 2004 tsunami had turned the tide. "PSS used to be seen as something to do after basic survival needs were met – the tsunami emphasized how mentally affected people are, and support in that realm can be life-saving: if you make people more resilient, they're less likely to engage in high-risk behaviour and be victim to a variety of preventable [problems]."

What are the constraints?

PSS "still has some way to go before the value of education in children's psychosocial wellbeing is really understood," said Save the Children's Haines.

Governments and practitioners often had to be persuaded to take a holistic approach. "A government might put its health ministry in charge of PSS, and the ministry will post a couple of psychiatrists in the field, and you will end up with a purely medical model," said Wessells. The specialized nature of the training meant many psychologists and social workers each took "an inappropriate, silo approach" to providing help.

There is a lack of evidence as to what works and what does not. "In the absence of this [evidence] it can be difficult to convince policy leaders to make it [PSS] as high a priority as many think it should be," said Rakotomalala. "People think it is so important to set up toilets, but they don't necessarily take into account how people are feeling."

It is not always about money, said Papinutto. Although the sector has received more cash, there is still an absence of good needs assessments on the ground, and despite minimum guidelines, agencies offering low-quality, inappropriate responses are still able to operate.

When is your work done?

Emergency interventions are finite, but psychosocial wellbeing could take years to achieve, and implementing the various tiers of the PSS response takes different periods of time. Haines said emergency education should start as early as possible, because a crisis was inevitably a long-term endeavour.

"Communities are not moving on when they are stuck in the past," said MSF's De Jong. "It is like losing someone; you are supposed to feel grief, anger and sadness, but after, say, nine months, you should also want - at least partly - to start to live again."

An intervention was working "When we see a community functioning again, when they are able to direct their energies towards the future, and are able to deal with the issues of the past without revenge or anger," he said.

"When they can look after themselves and others, and their caring capacity is restored; when new or old mechanisms of leadership are re-established or re-started - these are some indicators of recovery."