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The invisible wounds of armed conflict

DOI: https://doi.org/10.4414/sanp.2019.03037
Publication Date: 11.08.2019
Swiss Arch Neurol Psychiatr Psychother. 2019;170:w03037

Ortega Mateo Jaramilloa, Tschakarjan Senopb

a Comité Internacional de la Cruz Roja (CICR), Bogotá, Colombia

b International Committee of the Red Cross (ICRC), 1202Genève, Switzerland

Summary

One in four people in the world have a mental or neurological disorder at some point in their lives. People affected by conflict and other situations of violence are particularly vulnerable. Furthermore, conflict situations also strain healthcare systems with already scarce or inadequate resources. The International Committee of the Red Cross (ICRC) works to ensure that the people affected have access to basic healthcare – including mental healthcare – that meets universally recognised standards. The ICRC aims to address psychological and psychosocial needs in a holistic manner, assessing and responding to the various needs, and regularly consulting the individuals and communities concerned. It also takes a multidisciplinary approach. The ICRC has developed a set of activities that seek to respond to different mental health and psychosocial needs and that can be adapted to the different populations the ICRC serves. There is still a large gap between mental health and psychosocial needs and the actual care provided worldwide. The ICRC works to address and reduce this gap.

Keywords: conflict situations, mental health, healthcare, psychosocial needs, ICRC

The International Committee of the Red Cross (ICRC) works to ensure that people affected by conflict and other situations of violence have access to basic healthcare – including mental healthcare1 – that meets universally recognised standards. As part of its healthcare activities, the ICRC has considerably increased its response to mental health and psychosocial needs. It now runs over 120 mental health and psychosocial support projects involving more than 260 expatriate and local mental health professionals in 50 different countries, compared with just 10 projects in 8 countries back in 2010.

A growing number of studies underscore the importance of mental health and psychosocial support. According to the World Health Organization (WHO), one in four people in the world are affected by mental or neurological disorders at some point in their lives. This accounts for 13% of the total global burden of disease [1].

People affected by armed conflict and other situations of violence are particularly vulnerable; they are likely to develop new mental health problems, and pre-existing mental disorders may resurface or be exacerbated. Conflict situations also put a further strain on healthcare systems with already scarce or inadequate resources, undermining their ability to provide high-quality care to those who need it the most. South Sudan, for example, has a population of 13 million but only one local psychiatrist and no psychologists.

In 2017, the ICRC developed guidelines to frame the organization’s approach to mental health and psychosocial needs during and after armed conflict and other situations of violence [2]. The guidelines aim to harmonise mental health and psychosocial support projects within the organisation, combining international evidence-based recommendations and best practices and drawing on the expertise of teams working for the ICRC in various contexts around the world.

The International Committee of the Red Cross response to mental health and psychosocial needs

The ICRC aims to address psychological and psychosocial needs in a holistic manner, promote coping mechanisms and prevent further mental health and psychosocial problems by working at the individual, family and community levels. For this purpose, it developed the “pyramid of mental health and psychosocial needs”, which is based on the Inter-Agency Standing Committee’s2 pyramid (fig.1) [3]. This framework differentiates between social, psychosocial, psychological and specialised mental health needs and encompasses everything from social support to psychiatric support. This holistic approach ensures that the full range of mental health and psychosocial conditions are covered, adapting the interventions at each level.

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Figure 1
The pyramid of mental health and psychosocial needs developed by the International Committee of the Red Cross.

The ICRC assesses and responds to all these different needs when implementing mental health and psychosocial support projects, regularly consulting the individuals and communities concerned in order to better determine their needs and interests. This approach ensures that the activities are adapted to the local culture and delivered in a manner that promotes dignity, and respects religious and cultural practices. In order to ensure a proper continuum of patient care, the ICRC also takes a multidisciplinary approach. Those working on mental health and psychosocial support programmes therefore work closely with staff involved in all other ICRC healthcare programmes (primary health care, hospital services, physical rehabilitation, first aid and pre-hospital services, and healthcare in detention). They also work closely with other ICRC departments, such as the economic security and protection teams.

The ICRC’s mental health and psychosocial support programmes are designed to build local capacities by training community actors, local psychologists or other mental health practitioners, depending on the context. Transferring knowledge and skills in conflict situations is about more than just theoretical training – it involves supervising the application of the skills learned through regular follow-up. Provision of effective training is an ongoing process that requires thorough practice and close mentoring, monitoring and supervision, all delivered by qualified trainers.

Evidence-based monitoring and evaluation are also key components of the ICRC’s mental health and psychosocial support activities, and standardised scales are used in every project. Given that the ICRC operates in a diverse range of countries and communities, these scales need to be cross-culturally validated and translated into local languages. They are used to measure changes in three main outcome indicators: distress reduction in terms of the intensity and frequency of psychological and psychosocial symptoms; improvement in daily psychological and psychosocial functioning; and development of individual coping mechanisms in order to build resilience and prevent further harm.

Mental health and psychosocial support programmes: healing the hidden wounds

The ICRC’s mental health and psychosocial support projects respond to the needs of different groups affected by armed conflict and other situations of violence in the field. These groups include families of missing persons, victims of violence (including victims of sexual violence and child victims of violence), people who have been wounded or acquired disabilities as a result of conflict, those providing assistance within an affected community (“helpers”), people deprived of their liberty, former detainees and people affected by emergencies.

Individuals across these groups often present similar symptoms (psychosomatic symptoms, as well as symptoms of depression and anxiety). Affected individuals can feel emotionally and socially isolated; they may also feel that no-one understands their suffering and that they are unable to reach out for help. Most of these reactions are a normal response to an abnormal situation, but there is a tendency to view all people with mental health and psychosocial needs as mentally ill. As a result, victims often face rejection and stigma, making it difficult for them to get the assistance they need and leaving them more vulnerable to further ill-treatment.

The ICRC has developed a set of activities that seek to respond holistically to different mental health and psychosocial needs and that can be adapted to the different populations the ICRC serves.

  1. Mental health activities:
  2. − basic psychological support (individual and group)
  3. − psychotherapeutic support (individual and group)
  4. − specialised care and referrals
  5. Psychosocial support activities:
  6. − psychosocial group activities
  7. − information and sensitisation activities
  8. − referrals

Although these issues are now garnering more attention, there is a large gap between mental health and psychosocial needs and the actual care provided worldwide [4]. The ICRC works to address and reduce this gap by building local capacities, with a view to stabilizing and improving the mental health status and psychosocial well-being of individuals and communities.

The ICRC’s Guidelines on Mental Health and Psychosocial Support are available from the ICRC’s online shop. They can also be downloaded for free in both English and French.

Footnotes

1 The ICRC uses the term “mental health” to denote psychological well-being. Mental health interventions aim to improve psychological well-being by reducing levels of psychological distress, improving daily functioning and ensuring effective coping strategies. Such interventions are overseen by a mental health professional and target individuals, families and/or groups.

2 The Inter-Agency Standing Committee (IASC) is the primary mechanism for coordination between key UN and non-UN actors for humanitarian assistance. In 2004, the IASC published “Guidelines for Mental Health and Psychosocial Support in Emergency Settings”: the insights of numerous agencies and practitioners worldwide on how to respond appropriately during humanitarian emergencies.

Acknowledgement

The authors thankMilena Osorio, main author of the guidelines presented in the article, for final critical review of the manuscript, and Paloma Vega for writing assistance and editing the manuscript.

Funding / potential competing interests:

No financial support and no other potential conflict of interest relevant to this article was reported.

Correspondence

Senop Tschakarjan MD, International Committee of the Red Cross (ICRC), Avenue de la Paix 19, CH-1202 Genève, Switzerland, stschakarjan[at]icrc.org

References

1 Vigo D, Thornicroft G, Atun R. Estimating the true global burden of mental illness. Lancet Psychiatry. 2016;3(2):171–8. doi:. http://dx.doi.org/10.1016/S2215-0366(15)00505-2 PubMed

2 International Committee of the Red Cross. Guidelines on Mental Health and Psychosocial Support. Geneva: ICRC; 2017.

3 Inter-Agency Standing Committee. Guidelines for Mental Health and Psychosocial Support in Emergency Settings. Geneva: IASC; 2007.

4 World Health Organization. Depression and Other Common Mental Disorders. Geneva: WHO; 2017.

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