Content uploaded by Tessa Ubels
Author content
All content in this area was uploaded by Tessa Ubels on Jan 06, 2021
Content may be subject to copyright.
10 MT BULLETIN OF NVTG 2020 DECEMBER 04
REVIEW
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.
UNCOVERING UNINTENDED 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.
WHAT ARE THE KNOWLEDGE GAPS?
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
DECEMBER 04 2020 MT BULLETIN OF NVTG 11
REVIEW
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.
WAYS FORWARD
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.
CONCLUSION
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
tessa.ubels@ru.nl
References and background information
about literature on page 18.
18 MT BULLETIN OF NVTG 2020 DECEMBER 04
CONSULT ONLINE
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.
CONCLUSION
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
sulley.salim.sw@gmail.com
Daily Krijnen, MD
Infectious Disease Control, Municipal
Health Services Zuid Limburg, the
Netherlands
dailykrijnen@gmail.com
Maud Ariaans, MD
Global Health and International Medicine in
training, Gelre Ziekenhuizen Apeldoorn, the
Netherlands
maud_ariaans@hotmail.com
REFERENCES
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)
BACKGROUND INFORMATION
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.
REFERENCES
1. Mi nistry of Forei gn Affairs. D eclaration: m ind the
mind now [I nternet]. Ams terdam: Gover nment of the
Netherl ands; 2019 [updated 2 019 Oct 8; cited 2020
Oct 9]. 5 p. Av ailable from: htt ps://www.govern ment.
nl/document s/diplomatic-statement s/2019/10/08/
amsterdam- conference-declaration
2. Ventev ogel P, Van Omme ren M, Schilpero ord M, et
al. Improv ing mental hea lth care in huma nitarian
emergenc ies. Bull World Healt h Organ. 2015 Oct
1;93(10):666 -A. DOI: 10.24 71/BLT.15.156919
3. Li ese BH, Gribble RSF, Wick remsinhe MN.
Intern ational fund ing for mental hea lth: a review
of the las t decade. Int Healt h. 2019;11(5):361-
9. DOI: 10.1093/int health/ihz040
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;
2019 [date un known; cited 2 020 Oct 9]. Avail able
from: https://www.government.nl/topics/mhpss/
integration-of-mental-health-and-psychosocial-support-
in-human itarian -response/why-is-it-i mportant-to -
integrate -mhpss-into-humanitarian-respon se
5. Wesse lls MG. Do no harm: Towa rd contextua lly
appropri ate psychosoci al support in int ernational
emergenc ies. Am Psychol. 2 009 Nov;64(8):842 -
54. DOI: 10.1037/0003-0 66X.64. 8.842
6. Sha h SA. Ethica l standards for t ransnational
mental he alth and psych osocial suppor t (MHPSS):
do no harm , preventing c ross-cult ural errors and
invit ing pushback. C linical Soc ial Work Journal.
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/j.so 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 ww.who.in t/
mental_health/emergencies/9781424334445/en/
10. Koch D -J, Schulpen L . Introduction t o the
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
conseque nces of development pro grams: how mixe d
method s can contribute . Eval Program Pla nn. 2016
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.
13. Blanc het K, Ramesh A , Frison S, Warren
E, Hossa in M, Smith J, et al. Ev idence on
public hea lth intervent ions in humanit arian
crise s. The Lancet . 2017;390(10109):2 287-
96. doi:10.1016/S0140-6736(16)30768-1.
