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FMR 66Mental health and psychosocial supportMarch 2021www.fmreview.org/issue66UNHCR/Caroline Gluckand communities to release their potential torecover, maintain or regain their resilienceand perspective, to rebuild social cohesion,to resume their livelihoods, and to fosterreconciliation. Unlocking this potentialthrough MHPSS is essential to alleviatingthe effects of conflict, natural disasters,displacement and pandemics. And it canbe done – provided that we work in closepartnership with affected populations,grassroots organisations and civil societygroups, making use of and building onexisting experience, expertise and tools.I very much welcome this issue of ForcedMigration Review dedicated to MHPSS,relevant for practitioners, policymakersand researchers alike. It is an excellentgateway to a rich body of knowledge andexpertise that need to be disseminated.And I call on all governments and actors towork collaboratively and with strengthenedcommitment to address the mental healthneeds of displaced people around theworld and to make full use of the potentialof MHPSS. Because MHPSS helps to keepboth our minds and our societies at peace.Sigrid KaagMinister for Foreign Trade and DevelopmentCooperation of the Kingdom of the NetherlandsMHPSS@minbuza.nl1. bit.ly/Guterres-mental-health-covid-video2. WHO (2020) The impact of COVID-19 on mental, neurological andsubstance use services: results of a rapid 24553. See ‘Enhanced Integration of MHPSS & Peacebuilding’, October2020 bit.ly/MHPSS-peacebuilding-video-Oct20204. International Conference on Mental Health and PsychosocialSupport in Crisis Situations – Amsterdam, 7-8 October erdam Declaration bit.ly/Amsterdam-Declaration-Oct20195. bit.ly/IASC-MHPSS6. bit.ly/RCRC-MHPSS-Resolution-Dec20207. See bit.ly/high-level-MHPSS-crises-Dec2020-video8. bit.ly/IASC-MHPSS-CallForAction-Dec20209. WHO (2021) Promoting mental health preparedness and response forpublic health emergencieshttps://apps.who.int/gb/ebwha/pdf files/EB148/B148(3)-en.pdfCreative tensions in the framing of MHPSSAlastair AgerThe tensions and challenges involved in the development over recent decades of the fieldof practice now known as mental health and psychosocial support (MHPSS) will continue toshape questions of implementation, prioritisation and impact.The earliest use of the term ‘psychosocial’in the context of forced migration that Ihave found is by Hertha Kraus in a 1939Special Issue of the The Annals of the AmericanAcademy of Political and Social Science.1 Herpaper addressed the sources of stress forthose resettling in “a strange country” andnoted the psychological and social nature ofthese beyond the legal, political and economicstressors considered by other authors.The term only came into wider use in thefield in the 1990s, however. Barbara HarrellBond had written a chapter in her 1986classic Imposing Aid on “the over-socializedconcept of man” in which she had takenthe humanitarian field to task for its neglectof the psychological experience of forceddisplacement. In 1993 I was asked by her toput together a review of the issue of refugeemental health for Harvard’s Global MentalHealth report.2 However, it made only passingreference to the psychosocial concept, largelyto hint at the broader social and culturalcontext shaping refugee mental health.A subtle hint was inadequate toaddress the divisions that developed inthis fledgling field later in that decade. TheRwandan genocide and, particularly, thewars following the breakup of the formerYugoslavia brought the human side ofconflict and displacement into both publicawareness and humanitarian response.However, addressing mental health issuesin populations subject to ethnic-politicalpersecution also brought to the surface sharptensions between normative psychiatric5

FMR 66Mental health and psychosocial support6www.fmreview.org/issue66responses and broader community-basedapproaches.3 Derek Summerfield and PatBracken were particularly strong critics ofthe imposition of Western frames of illnesson the victims of human rights violationsand oppression. A meeting convened inthe late 1990s by the American Red Crossto consider appropriate means of responserevealed disparate factions with strongideological and methodological positions. Anumber of groups attending noted “a lack ofconsensus on goals, strategies and impacts”.Forging a consensusAs a result, in 2000 Carolyn Makinsonbrought together a number of leadinginternational NGOs working in this areawith academic groups from institutions thathad engaged with emerging approaches intoa Psychosocial Working Group to developa shared framing of the field.4 The groupproposed that psychosocial interventionsshould be defined by an interest in humancapital (notably in relation to the impact ofmental ill-health on individual well-being), insocial ecology (the relationships and broadersocial fabric disrupted by forced migration),and in culture and values (especially theerosion of rights and cultural norms). Theinteraction between these three domainswas also emphasised. The core challenge ofplanning appropriate interventions arosein negotiating the provision of supports inthese domains for an affected community ina manner that reflected genuine partnershiprather than neo-colonial imposition. Inpresentations to local actors in-country,it was always discussion of this last issuethat received the greatest attention.Subsequently, two members of thisworking group, Mark Van Ommeren andMike Wessells, were invited to co-chair anInter-Agency Standing Committee (IASC)process for the development of what becamethe IASC Guidelines on Mental Health andPsychosocial Support in Emergency Settings. Thisinitiative steered a process which focused onpractical implementation rather than theory,and on wide local and national consultationin order to address the concerns aboutimposition that had marked the precedingMarch 2021decade. The guidelines, published in 2007,5succeeded in providing a framework that bothintegrated diverse disciplinary perspectivesand was transparently accessible to diverseactors, local and international. In doing so,it accommodated major tensions withinthe field that had undermined coherenceand collaboration since its inception.A maturing, evidence-based fieldThe guidelines were substantially basedon emerging best practice, although it wasrecognised that the evidence base supportingthem was comparatively weak. While thesubsequent formulation of supplementaryguidelines for specific situations, such asthe Ebola outbreak, were important, themost significant development in subsequentyears has been gathering this much morerobust evidence base. This included a majorresearch agenda-setting exercise by WietseTol and colleagues6 that identified a numberof priority questions related to modalities ofintervention; these were family- and schoolbased approaches, assessment methods, andindicators for monitoring and evaluation.Other questions related to identifyingstressors, problems and protective factorsfrom the perspective of affected populations,sociocultural adaptation of interventions,and whether interventions address locallyperceived needs. The team facilitating thisconsensus exercise observed that the agendaemphasised “the generation of practicalknowledge that could translate to immediatetangible benefits for programming inhumanitarian settings, rather than addressingthe key debates that have dominated theacademic literature”. While this may be true,these two clusters of research questionsshow some resonance with a core tensionwithin the MHPSS framing: the formeremphasising the identification of effectiveand generalisable programme interventions,measures and indicators, with the latteremphasising the need for contextualisation.With sustained support for researchstudies in the area through programmes suchas Elrha’s R2HC programme,7 MHPSS movedfrom being one of the poorest supportedareas of humanitarian action in terms of

FMR 66Mental health and psychosocial supportMarch 2021evidence to one of the best. Much of the workhas focused on documenting the impact ofspecific intervention approaches that arecurrently implemented at scale, such asstructured activities within Child FriendlySpaces, or that are potentially scalable, suchas Programme Management Plus (PM ). Thiswork has contributed significantly to thegoal of identifying impactful programmaticapproaches, but also often points to theimportance of the goal of accommodatingthe diversity of contexts to which suchinterventions need to be adapted. The fieldhas thus matured to the point where thefocus is on refining and strengthening proveninterventions, or finding more effective orefficient modalities for their delivery.www.fmreview.org/issue66interventions. However, there are some verypromising recent examples of contextualadaptation being considered as a task tobe undertaken as a step-by-step processrather than as a vaguely stated ambition.Relieving suffering or driving long-termchange: Evaluations that have lookedat longer-term impacts of psychosocialinterventions have frequently found nomajor benefits for those in the programmescompared with those not receivinginterventions.8 Typically, this finding is notthe result of a ‘drop off’ in the well-beingof those who have attended programmingbut is rather the result of those who did notattend programming managing to ‘catchup’ in terms of adjustment. Despite shortterm benefits being noted, the interventionCreative tensionsis sometimes reported as having no impact.If, from the turbulence of the 1990s, the fieldThis raises the issue of whether psychosocialformed in the 2000s and matured in theprogramming should be aimed principally2010s, what prospect is there for the field inat the relief of suffering or at shaping longerthe next decade? On the research side, thereterm trajectories of adjustment. Promisesis a new research agenda-setting exerciseof longer-term benefit may reflect an undueunderway with support from a numbercapture by a longer-term resilience narrativeof donor agencies and intergovernmentalorganisations, reflecting the place that MHPSS rather than a relief of suffering narrative. Ibelieve that the positioning of psychosocialhas secured in humanitarian strategy. Thisinterventions as supporting populations inis a consensus-building exercise engagingdistress rather than demonstrating longwith diverse national and internationalterm benefits may be usefully established asstakeholders, whose outcome will notthe baseline expectation for the field. Thisbe known until well into 2021. However,is not to say that long-term benefits cannotthere are at least three issues that seembe secured but it may be appropriate forlikely to emerge from the exercise, andpsychosocial interventions to be judged in thethat will continue to engage practitionerssame way that food, shelter and most healthand researchers alike in the next decade.interventions are primarily judged – that is,on their amelioration of the suffering and riskScaling, fidelity and contextual adaptation:The challenge of balancing the development of in affected populations during an emergency,generalisable, effective interventions with the rather than on long-term trajectories of foodsecurity, settlement or physical well-being.need for cultural adaptation and sensitivityto the agendas of local actors will remain aFocused intervention versus strategy ofkey feature, if not the key feature, of work forengagement: Finally, I anticipate debatessome time to come. This is a significant task,continuing about the relative priority ofreflecting the recurrent MHPSS challengefocused MHPSS intervention programmes –of combining technical generalisabilitysuch as tackling severe mental distress andwith contextual understanding andthe consequences of gender-based violence –engagement, and scaling interventionsand broader-focused community engagementfor access by a much greater proportionstrategies promoting agency, ownership andof affected communities while retainingpeace-building. We can anticipate, however,fidelity to the active components of proven7

FMR 668Mental health and psychosocial supportwww.fmreview.org/issue66March 2021the development of clearer framing andtheories of change linking these differentforms of work. The breadth of influences onwell-being reflected in community-basedapproaches was acknowledged in Kraus’sinitial use of the term to describe the forcesshaping the experience of the resettlingrefugee and in much literature since; the valueof focused, targeted interventions addressingpsychological and emotional distress isnow also endorsed by a rich literature.International Mental and Behavioral Health, et/fmo:1082/PDFAlastair Ager aager@qmu.ac.uk @AlastairAgerInstitute for Global Health and Development,Queen Margaret University; Mailman School ofPublic Health, Columbia University7. Tol W et al (2020) ‘Improving mental health and psychosocialwellbeing in humanitarian settings: reflections on research fundedthrough R2HC’, Conflict and Health 14https://doi.org/10.1186/s13031-020-00317-61. Kraus H (1939) ‘Starting Life Anew in a Strange Country’,The Annals of the American Academy of Political and Social Science,Vol 203 www.jstor.org/stable/10218903. Ager A (1997) ‘Tensions in the psychosocial discourse:implications for the planning of interventions with war-affectedpopulations’, Development in Practice 7 (4)www.jstor.org/stable/4029006?seq 14. Psychosocial Working Group (2002) Psychosocial Intervention inComplex Emergencies: a Conceptual Frameworkbit.ly/PWG-conceptual-framework-20025. IASC (2007) IASC Guidelines on Mental Health and PsychosocialSupport in Emergency Settings bit.ly/IASC-MHPSS-guidelines6. Tol W et al (2011) ‘Research Priorities for Mental Health andPsychosocial Support in Humanitarian Settings’ PLoS Med 8(9)e1001096 doi.org/10.1371/journal.pmed.10010968. Panter-Brick C, Dajani R, Eggerman M, Hermosilla S, SancilioA and Ager A (2017) ‘Insecurity, distress and mental health:experimental and randomized controlled trials of a psychosocialintervention for youth affected by the Syrian crisis’, Journal of ChildPsychology and Psychiatry 59 https://doi.org/10.1111/jcpp.128322. Ager A (1993) ‘Mental health in refugee populations: A review’,Refugee Studies Programme, University of Oxford, for Project onEngagement of protection actors in MHPSS: the needfor cross-sectoral cooperationSarah Harrison, William S Chemaly, Fahmy Hanna, Nancy Polutan-Teulières andPeter VentevogelFostering the mental health and psychosocial well-being – within a comprehensive protectiveresponse – of people affected by humanitarian emergencies requires multi-sectoral actionand coordination.Many people living in areas affected byviolence and conflict experience a negativeimpact on their mental health, and one infive develop a mental health condition,which is much higher than for populationsnot affected by conflict.¹ Affected peoplemay require focused psychosocial supportor clinical mental health and psychologicalservices. First and foremost, however, affectedpeople need supportive social networksand to have their basic needs and securitymet in ways that preserve their dignityand agency, and uphold their rights.Over the last decade, supporting themental health and psychosocial wellbeing of people affected by conflicts,disasters and public health emergencieshas gained recognition as a vital part of thehumanitarian response.2 The 2007 IASCGuidelines on Mental Health and PsychosocialSupport in Emergency Settings have positionedMHPSS as an interdisciplinary field thatrequires a collaborative approach betweenmultiple humanitarian disciplines.3 In 2019,the global leadership for humanitarianresponse (the IASC Principals) re-affirmedthe decision to “treat MHPSS as a crosscutting issue that has relevance withinhealth, protection, nutrition, education andCamp Coordination and Camp Managementsectors/clusters, in all emergencies”.⁴Humanitarian programmes tend to focuson a specific sector while individuals, familiesand communities in emergency settings oftenpresent with multiple problems and needsthat cut across sectoral definitions. Since 2007,strong technical tools for specific MHPSSinterventions have been developed in areas

FMR 66Mental health and psychosocial supportMarch 2021such as health, nutrition, education, genderbased violence and child protection. But thewhole humanitarian response needs to adoptan MHPSS approach. This implies providinghumanitarian assistance in ways that supportthe mental health and psychosocial well-beingof persons of concern even when the primaryfocus of the intervention is sectoral. In short,promoting and protecting psychological wellbeing (positive mental health) and deliveringMHPSS services must be firmly embeddedwithin sectors and delivered across sectors.Objectives, resources and structurewww.fmreview.org/issue66humanitarian settings, serving as platformswhere agencies involved in MHPSSprogramming can discuss programmingissues. These are technical forums that workacross clusters and sectors – and with focalpoints in these where relevant – but donot replace the role of clusters and sectors,which retain accountability for activities andreporting. The exact configuration and coleadership should be decided at country levelby the involved MHPSS actors but MHPSSWGs are ideally co-chaired by a healthagency and a protection agency to balancediverse and complementary approaches.Integrating community-based MHPSSapproaches into other sectors often involvesworking in a different way rather than takingon new tasks: providing existing services inan effective way (focusing on dignity, agencyand participation of affected populations)rather than requiring stand-alone‘psychosocial programmes’ to be developed.6A protective environmentOne of the four protection principles in theSphere Handbook is to “assist people torecover from the physical and psychologicaleffects of threatened or actual violence,coercion or deliberate deprivation”.⁷ It isessential therefore that all humanitarianUNHCR/Will SwansonAddressing MHPSS requires a clearly definedspace for the topic within humanitariancoordination structures. The IASC Principalsagreed in their 2019 meeting to “reflectMHPSS indicators in relevant planningdocuments and establish dedicated budgetlines, as well as specific MHPSS codeswithin financial tracking systems andto support the creation and the work ofcountry-level MHPSS Working Groups inall migration, refugee and humanitariancontexts as crosscutting groups”. UN agenciesrecently

Mental health and psychosocial support 4 Foreword: No health without mental health Sigrid Kaag 5 Creative tensions in the framing of MHPSS Alastair Ager 8 Engagement of protection actors in MHPSS: the need f