[MUSIC] Humanitarian settings are increasingly affected by mental health problems. Although individuals living in these areas are resilient and often do well with their own coping strategies. Preexisting mental health and psychosocial status caused by humanitarian crisis can result in significant mental health and psychosocial difficulties. And additional organized psychosocial support may be needed. There is a growing recognition that humanitarian responses should include mental health and psychosocial support services to prevent these mental health problems. In order to learn more about mental health and psychosocial support services in humanitarian response, I have spoken with Professor, Wietse Tol, who's a global mental health professor at the section of Global Health at the University of Copenhagen. Wietse is also the mental health program director at the non government organizer named Health Right International. Wietse, thank you so much for being here today and willing to share your experience with mental health issues in humanitarian settings. Can you tell us what mental health issues people in humanitarian settings usually face? >> Thanks a lot for the invitation to talk about this important topic. Yeah, sure, it's actually a very wide variation of issues that are important when it comes to mental health in humanitarian settings. In the past, it used to be that we focused a lot on the common mental disorders like post traumatic stress disorder and depression and anxiety. We talked a lot about the mental health issues specifically related to stress. But actually when it comes to mental health in humanitarian settings, you have to think about the full range of mental health issues. Because humanitarian settings commonly occur in areas where there isn't really where there are very few resources for mental health. So you are building a mental health system often from scratch in remote areas. And that means that you also have to look at issues like psychosis, bipolar disorder, suicide, but also alcohol and other substance use disorders. Yeah, there's really a wide variation, and you need to look at the whole continuum of mental health concerns. >> What factors do you think can access about the risks of mental ill health in such settings? >> That's a really good question. And I would say there are largely two groups of risk factors. There's the group of risk factors that has to do with specific traumatic events that people have gone through. For example, as part of conflict or a disaster, the very upsetting threatening events. And we know much more about how those events influence mental health, particularly how they are related to common mental disorders. And we know much less about the second group of events. That's been a more recent topic of research. But that's the group of events that has to do with the ongoing situation in which you live, the ongoing misery on a day to day basis. And we found more recently that that's a really important group of risk factors, issues like domestic violence and ongoing chronic poverty, lack of access to healthcare, education disruptions. Those types of chronic ongoing issues are also really important in terms of mental health. But that's been a more recent area of research. So we know less about that. >> Since you have already conducted several research studies among refugee populations in humanitarian settings. Can you explain a little bit on what life in a refugee camp is like and where people seek mental health care in such settings? >> Yeah, yeah, it is the case that refugee camps can be very different depending on the kind of policies that apply. So, for example, recent refugee settings where I have done research were quite different. For example, in Tanzania, there are quite strict policies around whether refugees can leave the camp, whether they can have work, whether they can earn money, how much money they make. So their life is much more restricted. And it is challenging to think about what you can do to improve your life on a day to day basis. It's much more situation where you go from almost from handout to handout, from food delivery to food delivery. Whereas, for example, in Uganda, there is a much more open policy to a less restrictive policy towards refugees, where refugees are quite quickly admitted as legal refugees. Where they are provided with a plot of land, where they a place where they can settle. And they're allowed to work. They're allowed to leave the refugee settlements. Those are not camps, but more settlements. And so, yeah, at least, in theory, it is easier to think about how you can work towards improving your life, even though the resources are very limited also in many of those settlements. But those kinds of policies, I would say, really dictate how what camps look like. Then, of course, also decisions around shelter, what kind of housing, and how close housing is can be really, really different. So I've been to camps where people live in kind of semi permanent housing that's very close together, looks a bit like cardboard boxes next to each other. But in Uganda, for example, people live in settlements with housing that's quite similar to neighboring villages. So the settlements look much more like villages. >> So, how do people seek mental health care in such settings? Where do they get mental health treatment and care? And how easy it is for them to get this care? >> He has some mental health care seeking is influenced, I think quite strongly by people's beliefs around what causes mental health problems. And I think also what they see has helped, right? So there have been a lot of effort to integrate mental health into primary care settings. So in many refugee camps, you can go to your local health center and if you present with a mental health problem, there can be somebody there who has been trained with simple ways of managing mental health concerns. But what we see from the primary health care data, I was just looking at a paper where the UNHCR has been collecting data on what is actually presented in primary care settings. It seems that there is much more health care seeking for the more severe mental disorders and neuro psychiatric issues, neurological issues like epilepsy, psychosis. Those are presented more often to primary care settings. Then the common mental disorders which we know are very prevalent. But it seems that in many places people don't really bring those kinds of problems to primary care settings. And instead, I think a lot of people seek help from there immediately from their family members, from the elders, from wise people in their surroundings, from extended family members, and from religious institutions. So that informal care system, I think is a much more common place for people to find the support for mental health concerns. >> The issue of mental ill health is often ignored in humanitarian settings, and if it is dealt with, it is often in a biomedical context. Do there exist any a process to mental ill health that go beyond treatment in such response? >> Yes, I'd like to challenge that question a little bit. I think there is much more attention to mental health and psychosocial support. And then there has been a very long time. I would say that MHPSS, Mental health and psychosocial support is pretty much standard components of humanitarian response these days. Most large organizations would pay at least some attention to the topic. But it's true that there has traditionally been yeah, more of a biomedical view on providing mental health and psychosocial support. That is especially true in the research literature. I would say that from research we know much more about how to provide more specialized interventions treatment like you said, for particular mental disorders. And then specifically post traumatic stress disorder and depression. There is good evidence based for treatments for those disorders. But of course in practice there have been a lot of psychosocial programs, programs that don't focus on treatment. That's been a popular area of practice from the beginning of the field, I would say more community based interventions where the starting point is the concerns that people bring within communities. And where the focus is not so much on the individual suffering, but on improving the environment in which people live. Because the influence of the social environment on how people feel so strongly connected, especially as you can imagine in humanitarian settings, where environments are very stressful. And where many sources of well being are grossly lacking. So psychosocial programming focuses more on trying to improve the environment in which people live, trying to reduce risk factors, trying to strengthen protective factors. Protective factors like social support, connecting with culture, and yeah, protective daily practices, and ways to connect with neighbors and other community members and supportive ways. But the research literature hasn't really caught up with practice in this case, psychosocial programs are very popular in practice. But there have been few very rigorous evaluations of such kinds of programs. >> Can you give us some examples of mental health and psychosocial support programs currently existing in humanitarian settings? >> Yeah, so the there are these consensus based guidelines that have been very influential, the interagency standing committee guidelines for mental health and psychosocial support in humanitarian settings. And those have a pyramid. At the beginning of the document that divide the different kinds of activities into four layers from at the top, very clinical specialized programming. It's in a pyramid because that's supposed to represent the population, the affected population. So at the top are the fewest people. People with severe mental disorders requiring clinical management. For example, by specialists like psychotherapists and specialized social workers and psychiatrists in for example, health care settings or specialized trauma clinics or psychiatric unit. At the top of the pyramid all the way to the bottom, the least specialized support, where you, at the bottom of the pyramid, you integrate psychological and social considerations into general humanitarian response. So, for example, providing food relief in a way that does not disturb mental well being. So, for example, doing that in a participatory way, not dropping food from helicopters so that people have to scramble over the food and fight for it. But providing food rations or food for work interventions in a participatory way that respects people's dignity and the interventions in between. So the second layer from the bottom upwards, community based and family based interventions, where you support communities as a whole to rebuild lives and families. And the third layer is thinking about focused, but still not specialized supports. For example, integrating mental health into non specialized healthcare settings like primary care or maternal healthcare or HIV AIDS care settings. That's the range of MHPSS interventions you can think of.
