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Mental health and psychosocial support: hidden potential and harm



In this article, a new research approach is introduced to analysing the unintended and intended social effects of mental health and psychosocial support (MHPSS) interventions. This approach is longitudinal, to take into account long-term effects, multi-sited, to compare and contrast the influence of contextual factors, and pays special attention to psychosocial and multidomain interventions which are in need of a stronger evidence base.
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 commit-
ment to ‘look for opportunities to draw
attention to mental health and psy-
chosocial 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 interven-
tions addressing mental health needs,
ranging from psychotherapy to music
lessons. Policy makers and practitio-
ners 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, address-
ing 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 function-
ing of MHPSS, as we currently lack
a comprehensive understanding of
these interventions, and in particular
of their positive (potential) and nega-
tive (harmful) longer-term 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 psy-
chological wellbeing and erosion of
community’s trust in MHPSS.[6] For
example, he described the case of com-
batants 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 mate-
rial 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 indi-
vidual 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 set-
tings, 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, how-
ever, 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 interna-
tional cooperation’.[10] Most evaluations
exclusively focus on intended objec-
tives 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 underrepre-
sented 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.
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 interven-
tions 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 unan-
ticipated 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.
A new research approach is required
to reach a comprehensive understand-
ing 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 encompass-
ing understanding of the (unintended)
consequences for people who have par-
ticipated in a MHPSS intervention, such
as expanding a social network or finding
a job. Studying these long-term and
social effects requires a multi-disciplin-
ary 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 mul-
tiple geographical contexts to fol-
low people who have participated in
(perhaps multiple) MHPSS interven-
tions. 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 multido-
main interventions. These interven-
tions 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 interven-
tions. Psychosocial and multidomain
interventions do however offer a pos-
sible pathway to overcome the nega-
tive 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 contrib-
ute to understanding MHPSS
more comprehensively.
There is a need to deepen our under-
standing of the intended and unin-
tended 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 receiv-
ing 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 nega-
tive, deserve a more critical evaluation,
and this requires investment from the
academic and policy community.
Tessa Ubels
PhD candidate,Interuniversity Centre for
Social Science Theory and Methodology
(ICS)/ Department of Anthropology and
Development Studies, Radboud University,
Nijmegen, the Netherlands
References and background information
about literature on page 18.
facilitate sleep; cognitive restructuring
to replace maladaptive thought pat-
terns precipitating her anxious feelings;
insight therapy to provide understand-
ing of her conditions and the associated
symptoms, and coping techniques to
manage her behavioural changes due
to her current diagnosis. A week after
the initial intervention the patient
returned to explore its effectiveness.
She seemed to be more relaxed and less
worried about her situation. Finally, she
went through six sessions of cogni-
tive behaviour therapy and reported an
improvement in her thought patterns
and emotions, and was feeling hopeful
to proceed with her life activities. A post-
therapy HADS assessment indicated
an insignificant level of anxiety and
depression as reported by the patient.
The Clinical Psychology Centre still
faces teething problems but, as in this
case, can provide significant psycho-
logical help for a wide range of people
with diverse mental health challenges.
The centre also provides training and
supervision for both local and inter-
national students to prepare them in
caring for people with mental health
disorders. All these activities aim to
ensure a mentally healthy society with
insight and self-awareness. As this case
demonstrates, awareness and attention
to mental health problems, resulting
in a proper diagnosis and adequate
treatment, can significantly improve
the health of members of society.
Mohammed Salim Sulley Wangabi
Clinical psychologist, Greater Accra
Regional Hospital, Ghana
Daily Krijnen, MD
Infectious Disease Control, Municipal
Health Services Zuid Limburg, the
Maud Ariaans, MD
Global Health and International Medicine in
training, Gelre Ziekenhuizen Apeldoorn, the
1. Op pong S, Kretchy I A, Imbeah EP, et al. Ma naging
mental i llness in Ghan a: the state of common ly
prescr ibed psychotro pic Medicines. Int J M ent Health
Syst. 2016 Ap r 5;10:28. DOI: 10.118 6/s13033- 016-0061-y
Continuation of the article on Mental health and psychosocial
support by Tessa Ubels (on p10-11)
The literature search was conducted
by Vy Trân Nhât between 1 July 2020
and 20 September 2020. The seven
systematic reviews of MHPSS interven-
tions 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 target-
ing 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 unin-
tended effects and did not have any rele-
vant 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.
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mind now [I nternet]. Ams terdam: Gover nment of the
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of the las t decade. Int Healt h. 2019;11(5):361-
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4. Gov ernment of the Net herlands [Inte rnet]. Why is
it import ant to integrate MH PSS into humanita rian
response ? [Internet]. Gov ernment of the Net herlands;
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integrate -mhpss-into-humanitarian-respon se
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6. Sha h SA. Ethica l standards for t ransnational
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2012;40(4): 438-49. DOi: 10.100 7/s10615-011- 0348-z.
7. Miller K E, Rasmussen A . War exposure, d aily stressor s,
and menta l health in confl ict and post-con flict sett ings:
Bridg ing the divide b etween trau ma-focused and
psycho social frame works. Soc Sci Med . 2010;70(1):7-
16. DOi: 10.1016/ cscimed.2009 .09.029
8. Sum merfield D. A crit ique of seven assu mptions
behind p sychologica l trauma progra mmes in war-
affec ted areas. Soc Sc i Med. 1999 May;48(10 ):1449-
62. DOI: 10.1016/S027 7-9536(98)00450-X
9. Inte r-Ag ency Standin g Committee. IA SC
Guideli nes on Mental Healt h and Psychosoc ial
Support i n Emergency Set tings [Inter net]. Geneva:
IASC; 20 07 [date unknow n; cited 2020 Oc t 10].
205 p. Avail able from: https://w t/
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speci al issue ‘uninte nded effects of i nternationa l
cooperat ion’. Eval Program Pla nn. 2018 Jun;68:2 02-
9. DOI: 10.1016/j.eva lprogplan.2017.10.0 06.
11. Bamberg er M, Tarsilla M, Hess e-Biber S. Why so m any
“rigorou s” evaluations f ail to identif y unintended
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Apr;55:155-62 . DOI: 10.1016/j.evalprogplan .2016.01.001.
12. Jabee n S. Do we really car e about unintended
outcomes? A n analysis of eva luation theor y and
pract ice. Eval Progra m Plann. 2016 Apr;55: 144-
54. DOI: 10. 1016/j.evalpro gplan.2015.12 .010.
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96. doi:10.1016/S0140-6736(16)30768-1.
... This applies specifically to PSS because it deals with highly sensitive issues (Inter-Agency Standing Committee, 2007). Ubels (2020) shows that only 12 out of 134 (8.9%) assessed academic studies report unintended effects. Within this review of the grey literature, we will hence not only focus on intended social outcomes but also try to address unintended social outcomes. ...
... Within this review of the grey literature, we will hence not only focus on intended social outcomes but also try to address unintended social outcomes. Now is the time to bridge the divides between MHPSS research and practice (Tol et al., 2011;Ubels, 2020;Blanchet et al., 2017;Bangpan et al., 2017). Our search for social outcomes of PSS in the grey literature can help integrate both sides, by using the work from policymakers and practitioners to provide insights so far overlooked in academic research, which can guide the academic research agenda. ...
Full-text available
Policymakers, practitioners and academics expect mental health and psychosocial support (MHPSS) interventions to have social outcomes. Surprisingly, the existing academic literature on the effectiveness of MHPSS has focused almost exclusively on clinical outcomes. The evidence base of MHPSS interventions is in that way limited. To feed the research agenda on MHPSS (i.e., MHPSS-SET2), this scoping review analyses the presence and understanding of social outcomes in the grey literature. Open-access documents were systematically searched from various online grey literature databases and websites of organisations. Documents which describe psychosocial programming in low- and middle-income countries for people affected by humanitarian emergencies were included. Data characteristics were extracted, such as the type of document, intervention and outcome. A textual analysis of social outcomes was conducted to categorise the descriptions of these outcomes. A total number of 95 grey literature documents were included in the review. It was found that in 87% of the reviewed documents, social outcomes are being described. However, social outcomes have been poorly conceptualised both theoretically and methodologically, meaning that most documents lack definitions of theoretical concepts and measurement instruments. Mechanisms relating interventions to social outcomes have remained implicit. These findings are interpreted in light of key developments in the field of MHPSS, in particular the introduction of the Inter-Agency Standing Committee (IASC) guidelines, and the review traces the underexposed position of social outcomes back to the clinical historical roots of the field. In conclusion, those who develop and evaluate interventions should focus more structural attention on social outcomes to fully understand the possible impact of psychosocial interventions. Further harmonisation between academic research and practice is necessary, by drawing from practice-based insights on social outcomes as found in the grey literature, and using methods and measurement instruments from social sciences in MHPSS research.
... The typology is based on a review of different unintended effects that were identified in a four-year research programme called "the unintended effects of international cooperation" (2017-2021) (More information on the research program can be retrieved at This research programme comprises six structured literature reviews [4,[18][19][20][21][22], 16 working papers (The special working paper series on this topic can be retrieved here: https: //, 13 peer-reviewed academic articles and an international academic conference [8]. Based on a review of this work, we identified 10 different types of unintended effects by applying a 3*3*3*3 rule, meaning that a type of unintended effect was included in our typology if it matched the following criteria: ...
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International headlines often make mention of side effects of international cooperation, ranging from aid-fuelled corruption to the negative side effects of volunteer tourism. The OECD Development Assistance Committee, an international forum of many of the largest providers of aid, prescribes that evaluators should consider if an intervention has unintended effects. Yet the little that is known suggests that few evaluations of international cooperation projects systematically assess their unintended effects. To address this gap in assessing unintended effects, this study develops an operational typology of 10 types of unintended effects of international cooperation that have emerged in the literature and applies this to all 644 evaluations of the Netherlands’ development cooperation between 2000 and 2020 using structured text mining with manual verification. The results show that approximately 1 in 6 evaluations carefully considered unintended effects and identified 177 different ones. With the exception of 5, these could be classified in 9 of the 10 typologies, indicating that this typology can guide international development cooperation to systematically consider and assess its unintended effects. International development planners, researchers and evaluators are recommended to henceforth make use of and improve this operational typology.
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Mental health represents one of the most significant and increasing burdens to global public health. Over the past decade, the once invisible field has gained recognition on the global health agenda and this increased recognition is expected to increase international funding for mental health. Our review found that few studies have been conducted as to the level of international funding for mental health and there is a need for a differentiated assessment. We conducted such an assessment of global development-related assistance for mental health between 2006 and 2016 and established categories to serve as a baseline for future measurement. We found that development assistance specifically dedicated to mental health accounted for just 0.3% of all development assistance for health. Given the limited public expenditure on mental health by national governments in low- and middle-income countries, renewed efforts by the international community and development partners to substantially increase funding for mental health are critical.
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Climatic and geological hazards con-tinue to take their toll, as seen recently following the devastating earthquake in Nepal, cyclone in Vanuatu and flooding in China, Malawi and Myanmar.Although estimated rates of mental disorder after conflict vary due to differ -ences in context and study methods, a meta-analysis of methodically stronger surveys indicate average rates of 15–20% for depression and post-traumatic stress disorder.
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In the aftermath of international emergencies caused by natural disasters or armed conflicts, strong needs exist for psychosocial support on a large scale. Psychologists have developed and applied frameworks and tools that have helped to alleviate suffering and promote well-being in emergency settings. Unfortunately, psychological tools and approaches are sometimes used in ways that cause unintended harm. In a spirit of prevention and wanting to support critical self-reflection, the author outlines key issues and widespread violations of the do no harm imperative in emergency contexts. Prominent issues include contextual insensitivity to issues such as security, humanitarian coordination, and the inappropriate use of various methods; the use of an individualistic orientation that does not fit the context and culture; an excessive focus on deficits and victimhood that can undermine empowerment and resilience; the use of unsustainable, short-term approaches that breed dependency, create poorly trained psychosocial workers, and lack appropriate emphasis on prevention; and the imposition of outsider approaches. These and related problems can be avoided by the use of critical self-reflection, greater specificity in ethical guidance, a stronger evidence base for intervention, and improved methods of preparing international humanitarian psychologists.
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This paper seeks to bridge the divisive split between advocates of trauma-focused and psychosocial approaches to understanding and addressing mental health needs in conflict and post-conflict settings by emphasizing the role that daily stressors play in mediating direct war exposure and mental health outcomes. The authors argue that trauma-focused advocates tend to overemphasize the impact of direct war exposure on mental health, and fail to consider the contribution of stressful social and material conditions (daily stressors). Drawing on the findings of recent studies that have examined the relationship of both war exposure and daily stressors to mental health status, a model is proposed in which daily stressors partially mediate the relationship of war exposure to mental health. Based on that model, and on the growing body of research that supports it, an integrative, sequenced approach to intervention is proposed in which daily stressors are first addressed, and specialized interventions are then provided for individuals whose distress does not abate with the repair of the social ecology.
The ‘Evaluation and Program Planning’ journal has contributed to the launch of an academic discussion of unintended effects of international cooperation, notably by publishing in 2016 articles by Bamberger, Tarsilla, & Hesse-Biber and by Jabeen. This special issue aims to take up the academic challenges as laid down by those authors, by providing among others a clear typology and applying it, by outlining various methodological options and testing them, and elaborating on suggestions on how to deal with the barriers that prevent unintended effects being taken into account. This special issue makes clear that it is possible to reduce the share of unforeseen effects of international cooperation. Turning the spotlight on unintended effects that can be anticipated, and aiming to make progress on uncovering those that are particularly difficult to detect and debunking those that are exaggerated is the task that lies ahead of us.
The concept of ‘unintended outcomes’ has a long history. Contributions to the topic have appeared under the guise of various disciplinary lenses, including programme evaluation. There is now solid consensus among the international evaluation community regarding the need to consider side effects as a key aspect in any evaluative study. However, this concern often equates to nothing more than false piety. In this article, shortcomings of existing theoretical developments to evaluate unintended outcomes are identified. Current evaluation practices in international development are then analysed to demonstrate ways in which unintended outcomes remain peripheral. Reasons for neglect are discussed and the need for a stronger re-focusing on unintended effects of development interventions is advocated.
Many widely-used impact evaluation designs, including randomized control trials (RCTs) and quasi-experimental designs (QEDs), frequently fail to detect what are often quite serious unintended consequences of development programs. This seems surprising as experienced planners and evaluators are well aware that unintended consequences frequently occur. Most evaluation designs are intended to determine whether there is credible evidence (statistical, theory-based or narrative) that programs have achieved their intended objectives and the logic of many evaluation designs, even those that are considered the most “rigorous” does not permit the identification of outcomes that were not specified in the program design. We take the example of RCTs as they are considered by many to be the most rigorous evaluation designs. We present a numbers of cases to illustrate how infusing RCTs with a mixed-methods approach (sometimes called an “RCT + " design) can strengthen the credibility of these designs and can also capture important unintended consequences. We provide a Mixed Methods Evaluation Framework that identifies 9 ways in which UCs can occur, and we apply this framework to two of the case studies.
Important components of bioethics are routinely underappreciated in cross-cultural and transnational mental health and psychosocial support (MHPSS) efforts. This article provides case examples of cultural errors and/or harm by outsiders delivering MHPSS on different continents. The errors illustrate violations of informed consent (principle of autonomy) and avoiding harm (nonmaleficence). Ethical cultural adaptation standards are presented in order to avert such errors. Given the real risk of outsiders applying culturally erroneous and/or harmful practices in the process of delivering aid, the ability to discern pushback (resistance and redirection by intended beneficiaries) can yield ethically significant data. Actively inviting pushback is proposed as an additional methodology for ethical cultural adaptation with the purpose of at least gaining informed consent and, at best, shaping the most beneficent MHPSS.
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