Integrating Mental Health Services
into Humanitarian Relief Responses
to Social Emergencies, Disasters,
and Conflicts: A Case Study
Robert Henley, PhD
Randall Marshall, MD
Stefan Vetter, MD
Utilizing lessons learned from development and implementation of “Project Liberty” in New
York City, created in response to the attacks of September 11, 2001, this paper explores the
importance of integrating structured mental health services with community-based social service
programs offered in large-scale humanitarian relief responses. Relevant international research
studies illustrating similar integrated programs are also reviewed. The primary approach is
community-based and resilience-enhancement focused, offering structure, stability, support, and
community cohesion, with an added integrated screening component to identify persons with
severe treatable mental health conditions. Because there is thus far little evidence that resilience-
enhancing programs are effective for severe mental health conditions, a secondary program
initiated in parallel would be staffed with more specialized providers offering services for those
referred from the primary program. The key implication supports the establishment of more
effective links between programs and professionals from different disciplines, who then can more
effectively implement integrated program responses to large-scale disasters.
Community-Based Interventions after Humanitarian Emergencies
In both U.S. and international relief settings, a primary emphasis in response to such
humanitarian crises as disasters, conflicts, or social emergencies is placed on addressing the
immediate potential dangers to community cohesion and resource loss,1also referred to as
Address correspondence to Robert Henley, PhD, Centre for Disaster and Military Psychiatry, University of Zurich,
Birchstrasse 3, 8057, Zurich, Switzerland. Phone: +41-43-2339540; E-mail: firstname.lastname@example.org.
Stefan Vetter, MD, Centre for Disaster and Military Psychiatry, University of Zurich, Zurich, Switzerland. Phone: +41-43-
2339540; E-mail: email@example.com
Randall Marshall, MD, Clinical Research, Sepracor Inc, 84 Waterford Drive, Marlborough, MA, USA. Phone: +1-508-
7874267; E-mail: Randall.firstname.lastname@example.org
Journal of Behavioral Health Services & Research, 2010. c) )2010 National Council for Community Behavioral
Mental Health Services into Humanitarian Relief ResponsesHENLEY et al.
collective recovery.2,3Threats to the community from these events include fragmentation,
persistence of the acute response to disaster, violence, and economic collapse (if the community
is not able to return to some semblance of collective functioning).
In acute post-emergency settings, particularly in developing countries, there is an understandable
reliance on establishing community-based psychosocial programs rooted in the resilience-
enhancement of individual and collective competencies to cope with severe stressors. A strength
of these programs is that they can utilize a broad range of local professionals, para-professionals,
and community services providers (e.g., school teachers, coaches and ministers) who can be taught
basic intervention skills focused on encouraging healthy relationships, teaching problem-solving
skills and coping strategies, and encouraging engagement and cohesion within a community.4–8
One specific example of this is the “Peer Support” approach, which involves training individuals
who have mental illness to become peer counselors, who then help others who are mentally ill to learn
well-developed curriculum and support base in the United States (http://gainscenter.samhsa.gov/atc).
Mentally ill peer counselors utilize approaches that do not focus on psychiatric issues but instead on
empathically listening to and understanding the experience of others who also suffer from mental
illness and then offering practical guidance to develop adaptation strategies. This has resulted in
diverting people from unnecessarily utilizing psychiatric services that are often already overburdened
after a disaster.9This and other such strength-based approaches may be the de facto response in
developing countries simply because highly trained mental health professionals are rarely, if ever,
available to a local community to help with post-emergency and social crisis recovery efforts.10–14
Nonetheless, there is yet little empirical evidence to suggest that psychosocial programs are
effective for treating the actual symptoms of the more serious and relatively common post-disaster
mental health disorders such as depression, complicated grief, PTSD, and psychoses. Adapting
basic mental health treatment principles to post-disaster settings is currently a major focus in
emergency and post-emergency services research, but for numerous reasons (not the least being
funding), humanitarian organizations and governmental agencies have often been unable to
integrate the newest mental health developments into their programmatic responses during and
after emergencies. This is especially true in international settings,15,16and as Belfer notes in his
assessment of the current status of international mental health, relatively little is being done to
provide mental health services internationally under normal circumstances.17Nonetheless, a wide
range of evidence-based models are available, based on disparate theoretical approaches such as
biomedical, cognitive-behavioral, interpersonal, meditation-based, or psychodynamic, and relief
agencies and humanitarian organizations should attempt to find a “best fit” with local culture,
available resources, and the abilities of local healthcare providers.11,13,18,19
It is well established that there are multiple vulnerabilities to developing PTSD after exposure to a
“criterion A event” (i.e., when “a person experiences, witnesses, or is confronted with an event or
events that involved actual or threatened death or serious injury to the physical integrity of self or
others, and the person’s response involves intense fear, helplessness, or horror”).20This includes level
of social support,21ethnicity,21psychiatric history,22prior trauma or stress,21,23gender,24–28a number
of demographic variables (e.g., living alone, divorce, educational status), and prior history of PTSD.
Risk factors can be used to identify high-risk groups, particularly if resources are limited, for
participation in both peer support programs and screening/treatment programs.
An Integrated Care Response to a Large-scale Emergency: New York
At this point in time, there are still few examples of programs in which community-based
resilience-enhancing relief principles were successfully integrated with mental health screening and
The Journal of Behavioral Health Services & Research2010
treatment and fewer still that have been systematically evaluated for their efficacy and presented in
enough detail so that the larger humanitarian community could learn from them. One of the best
documented can be found in the overall response to the September 11, 2001 attacks in the U.S.29–35
Following the attacks of September 11, 2001 on New York City in the U.S., there was an
unprecedented effort to develop programs across both private and public institutions. These
programs aimed to meet a wide range of perceived need and encompassed a wide range of
interventions, both community-oriented resilience-enhancing programs and mental health service
A large-scale, government-funded effort in New York City, called “Project Liberty,” offered
primarily psychosocial public education and crisis counseling programs to over 1.2 million people
in a 2.5-year period.30,31It was based on the same core principles that inform international relief
work: that most persons were experiencing normal reactions to abnormal circumstances and that
programs fostering social support and healthy coping could assist most persons in dealing
effectively with the disaster and return them to productive and functional lives.32It made use of
outreach models that placed laypersons as well as professionals in the field. Counselors used
simple screening tools that served the multiple functions of providing mental health assessment,
evaluating the quality of services, and evaluating the program’s overall success in achieving
multiple objectives. These screening tools were kept simple, so persons with different training
levels could easily assess whether an individual needed more intensive treatment or not. It did not
delve into specific psychiatric factors too deeply or specifically other than to identify whether there
was an immediate need for further referral.
In addition, and for the first time in US history, New York State Office of Mental Health
expanded the Federal Emergency Management Administration program to integrate with services
for persons with severe mental health problems. “Project Liberty” was funded by the federal
government but administered by State and local city government, had considerable inter-
governmental cooperation, and also received the support and involvement of many local not-for-
profit service organizations.31,33A centralized triage center was created that could refer individuals
to both Project Liberty as well as to mental disorder treatment practitioners or treatment centers.
The triage center was accessible by a widely publicized free telephone number (1.800.
LIFENET).33Further, there was a monitoring and evaluation component built into the process
from the beginning, which enabled the collection of data about effectiveness and demographics,
helping to advance the field through refinement of screening tools that might be used in future
Project Liberty findings on the whole are a validation of the international relief model in that the
majority of persons affected by the 9/11 attacks eventually adjusted and returned to pre-event levels
of functioning.10,30,37,38However, studies in the first 8 weeks after the attacks also found that a
substantial minority of persons—10% in the first 5–8 weeks, or approximately one million adults—
had developed acute PTSD, major depressive disorders, or both as a direct result. At 1 year,
approximately 200,000 persons were estimated to have chronic PTSD.21,30,32,34,39,40–45These
surveys evoked alarm within the mental health community, as it was known that such a sudden
surge in new-onset psychopathology was beyond the capacity of the existing mental health system
to manage. Epidemiological studies suggest that not all people were reached who could have
benefited from services, despite all the efforts made.40,44,46
From the beginning, New York State committed to a program that involved integrating these two
disaster-relief approaches and to supporting evidence-based programs wherever possible. Since
there was no evidence that brief supportive counseling or community programs could help persons
with PTSD—in fact, evidence suggested that nonspecific psychosocial treatment is not as effective
as trauma-focused treatments—the two-track effort was eventually adopted. Treatment programs
were created so that persons who screened in for treatable disorders or who appeared to need
immediate professional help could be referred from community social services programs to mental
Mental Health Services into Humanitarian Relief Responses HENLEY et al.
health care. In addition, there were multiple outreach efforts developed to meet the needs of
specialized groups (e.g., fire, police, and emergency personnel), as well as the general population.
In support of this, training programs were initiated that eventually trained approximately 1,500
licensed clinicians in techniques for treating PTSD and complicated grief, funded largely through
philanthropic foundations.47The intensive, decision-science-based training programs increased
therapists’ knowledge of the basic principles of trauma treatment and enhanced their motivation to
apply them in practice.48
In the future, integrated services programs like Project Liberty could help promote increased
collaboration between international mental health and disaster relief communities too, raising
awareness that serious consequences of psychological trauma must also be addressed in post-
disaster intervention planning.12,19,30,49The most effective way to help traumatized populations
overcome their predicament—indeed, whether there is a superior approach, or are multiple, equally
efficacious approaches, or whether there are predictors of “best fit” between person, culture, and
treatment—remains open to further research.
Community-oriented resilience enhancement-based programs are increasingly being suggested
as the new approach to treating large non-Western international populations experiencing traumatic
conditions in post-emergency settings,50even though there have only been a few empirical field-
based research studies showing conclusive results to document effectiveness.51–55Moreover,
although the majority of persons affected by large-scale trauma do not develop long-term serious
mental health problems, when the scale of the trauma is large enough, the minority may still
represent a substantial number of persons (even if a small percentage)47,56and may place the
community at further risk for economic and social turmoil. The presence of substantial numbers of
persons suffering with incapacitating mental disorders may also complicate and obstruct relief
organization efforts, though a key issue in these circumstances is access to and utilization of
International Adaptations in Mental Health Treatment in Cultures
with Limited Resources
In recent years, a handful of international researchers in disaster and conflict settings have begun
trying to address the numerous serious psychological issues related to disaster, war, and torture
(and also by displacement from these and other emergencies). Although the New York programs
were exceptional with regard to availability of resources, other programs have been studied, and
successfully integrating mental health with community-based resilience enhancement practices in
response to emergency or severely adverse situations has been documented.
A West African psychosocial program served Liberian and Sierra Leonean survivors of torture
and war living in the refugee camps of Guinea.57This program had three main goals: (a) to provide
mental health care, (b) to train local refugee counselors, and (c) to raise community awareness
about war trauma and mental health using para-professional counselors under the close, on-site
supervision of expatriate clinicians, with a treatment model blending elements of Western and
indigenous healing. The core treatment component consisted of relationship-based supportive
group counseling, which was adapted to the realities of the refugee camp setting. Results from
follow-up assessments indicated significant reductions in trauma symptoms, with increases in
measures of daily functioning and social support during and after participation in groups.
In another study, the use of narrative exposure therapy (NET) was compared to the use of
psycho-education with aging survivors of political detention and torture in Africa. In narrative
exposure therapy, the patient is requested to repeatedly talk about the worst traumatic event in
detail, which stimulates re-experiencing emotions associated with the event. In the process, the
majority of patients undergo habituation of the emotional response to the traumatic memory. In
The Journal of Behavioral Health Services & Research 2010
addition to the reconstruction of the traumatic memory, this habituation consequently leads to a
remission of PTSD symptoms.58Results of this study found that use of NET had significantly
better results in helping reduce PTSD symptoms than did psycho-education practices alone.59
As little is known about the usefulness of psychotherapeutic approaches for traumatized refugees
who continue to live in dangerous conditions, research was done with Sudanese refugees living in a
Ugandan refugee settlement, this time comparing the use of NET, supportive counseling, or
psycho-education to treat PTSD. The study concluded that NET was a promising approach for the
treatment of PTSD, even for refugees living in unsafe conditions.15It was also suggested that
treatment of PTSD could increase the resilience competencies of refugees in coping with the
hardship of refugee camps.
In a similar vein, there were numerous studies done on a variety of innovative mental health and
psychosocial services offered during and after the Balkans conflict of the 1990s. In one study, a
group provided professional mental health support and trainings to a wide variety of professional
and para-professional service providers who were working both with severely traumatized
internally displaced refugees in Serbia and with traumatized children displaced from their families
in a hospital in Montenegro.60Because the training and support teams were small two person
teams, it was difficult to collect empirical data on the true efficacy of the services they provided.
Nonetheless, these researchers described evidence that offering skills—building trainings to care
providers and providing opportunities for caretakers of highly traumatized refugees and children to
talk about their own stresses—was a crucial service to offer in support of the ongoing important
care-giving work these people performed during war. In another project involving 20 survivors of
genocide from Bosnia–Herzegovina, psychiatrists offered “Testimony Therapy”61as a means of
resolving extreme trauma experienced during the ethnic cleansing. Testimony therapy, usually
conducted with survivors of human rights violations, involves the writing and public presentation
of autobiographical accounts of their experiences, as both a means of dealing with their
psychological trauma and giving historical account of the human rights atrocities that occurred. In
before and after assessments of the effectiveness of “testimony therapy,” results showed a
significant decrease in PTSD and depression symptoms and an improvement in overall
functioning.61Another study presented a case study of two Kosovar refugees living in a
Macedonian refugee camp who received a combined NET and Testimony therapy treatment. The
researchers concluded that this approach both relieved PTSD symptoms and allowed witnesses to
discuss human rights violations in a safe and respectful setting.62In post-war Bosnia–
Herzegovina,63the mental health system is being reformed from one based solely on hospital
delivered services to a community mental health based system with many different professionals
working together to offer services through both government and non-governmental agencies. The
new system has a wider focus on health promotion, prevention, treatment, and rehabilitation, and
much has been accomplished in these areas since the war. Unfortunately, the country still struggles
from a lack of resources, and this prevents full implementation of services needed to help heal the
survivors of war-related trauma.
Finally, several studies by one research team evaluated the natural course of posttraumatic stress
and depressive reactions in post-earthquake affected Armenia, as well as controlled trials of
treatment interventions. An adaptation of cognitive-behavioral therapy, called brief trauma/grief-
focused psychotherapy, was found to be effective in reducing PTSD symptoms and halting the
progression of depression. The authors encouraged the implementation of mental health
intervention programs in schools after disasters in order to reduce trauma-related psychopathology
in high-risk young people.64–67
Each of the above studies provides us with important anecdotal and empirical information about
how to improve psychosocial services offered to those in need of mental health services after or
even during humanitarian emergencies. Unfortunately, there are formidable barriers to introducing
research to identify what is effective in services-based programs in most international settings,
Mental Health Services into Humanitarian Relief ResponsesHENLEY et al.
especially during emergencies. Research typically is not a high priority for money and manpower
when there are so many pressing service needs. The advantages of collecting program data—
including the ability to make rational, incremental improvements in the quality and efficiency of
programs—may be appreciated and even desired, but less often implemented. In some cases,
research may even be perceived as an outright threat in that it could raise uncomfortable questions
about whether programs indeed are accomplishing what they purport to accomplish (and for which
they are being funded). These difficulties are compounded by the challenges of cross-cultural
program development and execution, as well as the problem of stigmatization of mental disorder
that varies considerably across cultures. Finally, there are often problems at the most basic level of
research, such as the lack of translated and culturally validated assessment tools and lack of trained
clinicians and researchers from the local culture to implement research (when there is funding).
One comprehensive report attempts to address these issues in practical detail,11outlining simple
ways to implement research to assess the effectiveness of programs in the field. The authors
suggest implementation of more “small action research pilot studies” using simple quasi-
experimental research designs in order to gather data before and after these programs have been
started, so best practices can start to be identified.
Of note, there has also been a recent increase in research evaluating the effectiveness of
resilience-enhancing programs for children and youth in severely adverse and/or traumatic
situations. For example, one study assessed the effectiveness of a classroom-based intervention to
support the enhancement of resilience processes in children from the Palestinian territories and
found it quite helpful to the children. Another study with Palestinian refugee camp children looked
at the importance that daily structured activities have in enhancing children’s resilience
competencies, protecting them in ongoing dangerous, stressful, and uncertain circumstances.54,55
There has also been an international study that examined whether there were differences in
resilience culturally and whether or not resilience practices could be integrated in program
development and implementation (in both cases affirmative). In each of these studies, it was found
that resilience interventions were associated with an improvement in children’s mental health, as
seen in improved function in their coping skills, problem-solving strategies, feelings of hope and
future thinking, as well as in improved family, school, and play relationships.53–55
In summarizing, international research to date is providing evidence that combining community-
based resilience-enhancement and mental health practices is possible, can facilitate the delivery of
effective services to many people who may not normally have access to them, and in fact offers
relief to mental suffering in diverse adverse situations in culturally sensitive ways. Much of
this can be accomplished through providing resources and training to local non-governmental
Discussion and Recommendations
What can be learned from the “Project Liberty” case study and from the other international
research studies of treatment after large-scale emergencies? First is that a simple systematic effort
to evaluate the effectiveness of all types of programs is essential because it will inform us of what
works best when trying to help large numbers of people after a humanitarian emergency. In some
cases, it may be possible to include small, brief, quasi-experimental research studies (e.g.,
comparing two credible but unstudied kinds of interventions) that can themselves inform evolving
programs of several years’ duration after a large-scale disaster. Monitoring and evaluating
community-based resilience-enhancing programs do not have to be burdensome and certainly do
not have to involve randomized research trials, although this remains the gold standard test for
comparing interventions. During Project Liberty, services programs were evaluated for purposes of
accountability, for purposes of refining and improving the program, and for eliminating aspects of
the program that were not effective or might have even be harmful to participants.11,13,30However,
The Journal of Behavioral Health Services & Research2010
monitoring and evaluation are not simply a measure of consumer satisfaction. They should
promote more in-depth understanding of the post-disaster environment and be able to evaluate and
possibly improve the interventions being evaluated.
A second issue worth emphasizing is that large-scale emergencies of all kinds expose a high
proportion of a population to life-threatening experiences, especially including various categories
of helpers.68,69Such experiences are very common, no matter what culture, and typically do not
result in the development of long-term serious psychopathology. However, where there is a strong
concurrent negative emotional reaction to the traumatic experience, such as the experience of
feelings of intense horror, fear, helplessness, anger, or shame, there is an increased risk for the
development of psychopathology. So while the experience of trauma is not in itself a psychiatric
illness, a traumatic experience can generate a wide range of normative emotional reactions: short-
term mental disorders involving disorientation, agitation, or panic that pass relative quickly or more
severe long-term disorders such as depression and/or posttraumatic stress disorder.20
To mitigate the abovementioned effects of a large-scale emergency, it is important to keep in
mind two overarching programmatic needs in post-emergency situations. First is to quickly
establish community-based collective recovery approaches using a variety of means, including
offering community-oriented resilience-based practices that create structure, provide stability, and
encourage community interaction and cohesion (such as sports, play, arts, wellness promotion,
educational, cultural, and religious practices).70,71Ideally, these programs will include brief
screening services to identify persons with more severe functional impairment and in need of more
intensive help. Second is to establish simple evidence-based treatments, whether group or
individual focused, adapted to the local culture and setting, that can benefit members of the local
population experiencing more serious mental health problems. In some settings, relevant applicable
treatments are already available; in others, expert input can assist in developing “evidence-
informed” programs that use basic principles of effective treatment, teaching locals who may have
basic skills how to use these methods. Multiple mechanisms for bidirectional cooperation and
referral should be built into a program’s structure, so that persons participating in resilience-
promoting interventions who are in need of treatment can be identified and offered more intensive
treatment. After treatment, these persons may become re-involved in supportive and wellness-
promoting programs in order to maintain their recovery, as well as to participate in supporting
others who may be in need (i.e., a form of the peer model program).
Implications for Behavioral Health
A key challenge in offering a full continuum of post-emergency services has been in establishing
effective links between different disciplines of professionals. Multidisciplinary cooperation is going
to require both ideological and educational adaptations from the different “camps.” Project Liberty
illustrated the interdisciplinary effort that is required to integrate low-profile screening, assessment,
and follow-up across a portfolio of programs. In developing countries, the emphasis must be for
skilled professionals to train local people who have the capability to be a helper, so these services
are locally sustained.
Another challenge is overcoming existing stigmas and cultural barriers to the use of mental
health services. This can be achieved through a process of continuous dialog, advocacy, and
learning between mental health experts and local community-based caregivers. Only through such
dialog and advocacy will behavioral health service providers and researchers be able to provide the
most effective “best” practices that are culturally responsive and acceptable.11,13,18,19The
overarching goal in any kind of programmatic or treatment outreach in culturally different contexts
is always to intervene in ways that will do good and avoid doing harm, and this is not always a
straightforward objective. For example, in greater New York, it was widely observed that
nonevidence-based treatments, such as single session debriefings or poorly implemented therapies,
Mental Health Services into Humanitarian Relief ResponsesHENLEY et al.
were suddenly being provided in ways that might have caused harm. In international post-
emergency situations, there have been anecdotal reports of the negative impacts of the swift
implementation and then precipitous withdrawal of new mental health services or programs, which
can be experienced as yet another traumatic loss; or of the prescribing of medications when there
can be little or no medical follow-up (and in many countries there already is little access to
affordable medicines).72Thus, it is critical to appreciate from the outset that, in most post-
emergency interventions, support for the development of sustainable services will take months and
even years to fully implement, and that a long-term view should be held.
Conflicts of Interest Statement
The authors of this paper have no financial or other conflicts of interest associated with the
publication of this paper.
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