How Helpful Are Interventions for War-Affected Civilians?
A new report sheds light on mental health programs in humanitarian settings.
Posted Dec 21, 2017
Humanitarian crises such as wars, forced migration, and natural disasters leave people vulnerable to developing both short- and long-term psychological difficulties. Although the majority of survivors of such experiences do not develop enduring psychiatric disorders, rates of psychological trauma, depression, prolonged grief, and anxiety, as well as various culturally specific expressions of distress, do increase significantly (Attanayake et al., 2009; Murthy & Lakshminarayana, 2006). This is due not only to the violence, destruction and loss that wars and disasters entail, but also to their devastating impact on the social and material conditions of everyday life (Hobfall, 2014; Miller & Rasmussen, 2014).
In response to compelling evidence of the adverse psychological effects of humanitarian crises, local governments, humanitarian organizations, and researchers have partnered over the past 25 years to develop a variety of mental health and psychosocial support (MHPSS) interventions aimed at fostering resilience and facilitating recovery in affected communities. An outstanding new report by Dr. Mukdarut Bangpan and her colleagues, commissioned by the Humanitarian Evidence Programme, sheds important light on the effectiveness of such interventions, which have been implemented and evaluated in a variety of humanitarian settings. These include war zones, post-conflict settings, and refugee camps, which collectively are the primary focus of studies reviewed in the report, as well as settings of natural disasters such as earthquakes and tsunamis.
The report critically examines not only the outcomes of intervention studies, but also the quality of those studies and the degree of confidence we should have in the findings of each. By weighing the findings of each study against the strength of its evidence, we get an impressively nuanced picture of what has been achieved and what remains to be done.
The report includes separate meta-analyses for studies of children and adults—in which the findings of many studies are combined to yield an assessment of intervention effects. It also involves separate analyses for quantitative and qualitative studies. In this post, I summarize and comment on the quantitative section; in a separate post, I'll discuss the qualitative findings. A word of warning: precisely because the report offers a nuanced view of the state of this challenging field, it offers few simple or straightforward answers to the seemingly simple question, "How well do MHPSS interventions work for war-affected people?"
Research with adults suggests reasons to be cautiously optimistic about the impact of mental health and psychosocial programming in conflict and post-conflict settings. There is moderately strong evidence that mental health interventions for war and disaster-affected adults are effective at reducing symptoms of PTSD, depression, and anxiety, the most commonly studied psychological problems in such settings.
The majority of interventions were delivered one on one by non-mental health specialists. The use of paraprofessionals (often trained community members) is an important adaptation in contexts where mental health professionals are generally scarce. Their effectiveness, with adequate training and support, is consistent with a growing body of evidence about the qualities and skills needed to be an effective helper (a topic I discuss in another post, "What are the Essential Qualities of Effective Therapists?").
It should be noted that several group-based clinical interventions currently being tested in low and middle income countries, also using trained community workers, were not included in the review because they are ongoing. Group interventions are clearly more practical (scalable) in terms of their reach; however, their effectiveness relative to individual treatment remains to be established. Even if they turn out to be somewhat less impactful than individual-level interventions, however, group programs have the capacity to reach for more people at substantially lower cost and therefore hold great potential in resource-limited settings.
Some degree of caution is warranted in viewing these generally encouraging findings, as the report notes that none of the evidence for positive effects in adults is strong. This may simply reflect the difficulty of conducting rigorous research in complex humanitarian settings. Such contexts are often chaotic, with frequent relocations of individuals and families. Moreover, mental health programs may be perceived as culturally unfamiliar or stigmatized, and participation in such programs is generally not a local priority relative to the urgency of securing basic material needs. The lack of strong evidence does not mean that intervention effects are not real; it does, however, underscore the importance of replication studies to see whether similar effects are found, which would support the trustworthiness of the original findings.
Interestingly, there is little evidence that mental health or psychosocial interventions increased social support among program participants. This is a noteworthy limitation, given the stress-buffering role that social support can play in situations of adversity. In the wake of natural disasters, pre-existing social support networks have been found to be a powerful protective factor against the development of PTSD (Norris et al., 2002). Interventions that can support the functioning of support networks in the aftermath of disasters could play a critical role in supporting resilience and recovery in affected communities. In refugee and other war-affected communities, where support networks are often destroyed or left behind, interventions that can help people develop new sources of support may hold promise in both the prevention and treatment of distress and disorder.
The lack of evidence for increased social support may simply reflect the prevalence in the review of individual-focused interventions, which by their nature are unlikely to strengthen social networks. It may well be that group interventions, including several currently being tested, do foster greater social support; indeed, this is typically an intended outcome of group, but not individual, interventions.
Finally, there is also insufficient evidence to reach any conclusions regarding the impact of interventions on psychosocial functioning—the ability to fulfill the roles and carry out the tasks of one's daily life. This lack of evidence likely reflects the bias of researchers towards the assessment of psychiatric symptoms and their comparative inattention to measuring functional impairment. This is unfortunate, as there is a growing consensus that psychosocial functioning is a critical indicator of overall psychological health and social well-being. In fact, the American Psychiatric Association has long specified that functional impairment is a necessary criterion for most of the diagnoses in its Diagnostic and Statistical Manual.
The picture with regard to MHPSS interventions with children and young people is comparatively muddled.
Programs can be roughly divided into those focused on fostering resilience ("preventive") and those that are focused on the treatment of distress.
Preventive programs aim at helping children develop the skills and resources needed to prevent the emergence of psychological difficulties and to promote healthy psychosocial development. They generally make use of various play and expressive arts activities, and may also include mindfulness techniques as well as activities aimed at strengthening social skills and relationships.
Treatment programs, in contrast, generally target highly distressed children and adolescents, typically with group-based clinical interventions. They may include many of the same techniques as preventive interventions, but are likely to also incorporate cognitive and behavioral techniques specific to the treatment of trauma (e.g., imaginal exposure) or depression (e.g., behavioral activation).
As with adults, these interventions are typically delivered by trained non-mental health specialists. Both types of interventions are most commonly school-based, though they may also be housed in community centers or child-friendly spaces.
What impact have these interventions had?
There is moderately strong evidence that clinical interventions can have a modest effect on reducing symptoms of PTSD, with a few studies showing marked improvements. On the other hand, several studies reported a worsening of PTSD among some participants. The report found compelling evidence for a small but positive effect on psychosocial functioning, and moderate evidence for improvement in conduct problems. Conversely, the findings suggested no impact on anxiety, and were decidedly mixed for depression: Some studies showed a modest decrease, others showed no effect, while still others reported an increase in depression among some participants. Overall, with some notable exceptions, clinical gains were modest, and varied considerably in their strength and duration.
Preventive interventions generally did not fare particularly well. On most outcomes, ranging from social support and hope to prosocial behavior and school performance, there was little reliable evidence that interventions significantly enhanced children's resilience or strengthened key life skills. There was also limited evidence of preventive effects with regard to common types of distress, though the typical study duration may not have been long enough to detect such effects. Among prevention programs that included clinical outcomes, there was some evidence of beneficial effects on trauma, conduct problems, and emotional problems. It's important to note that while the lack of compelling evidence for enhancing resilience may reflect an actual lack of program effects, it's also possible that methodological limitations led to weak or no evidence of effects that may actually have been present.
Humanitarian crises, both acute and prolonged, are tough settings in which to have a positive impact on mental health and psychosocial well-being. They are situations of extreme adversity, in which people struggle with exposure to war-related violence and loss while also contending with a host of daily stressors (e.g., poverty, hunger, inadequate housing, the loss of social support networks, increased community and family violence). In such contexts, the modest gains made by MHPSS interventions with adults are impressive. New interventions developed by the World Health Organization (WHO), which are currently being evaluated in several countries, hold great promise for strengthening and expanding the reach and impact of mental health and psychosocial programming.
On the other hand, the growing evidence of the impact of daily stressors on mental health suggests that interventions may be overly focused on healing distress without paying sufficient attention to ongoing sources of that distress. For example, we know that rates of intimate partner violence (IPV) spike among refugees and other war-affected communities; consequently, addressing PTSD among women experiencing IPV without also addressing the ongoing violence they experience at home is unlikely to show significant or lasting effects. Likewise, poverty exerts a powerful toll on individual and family well-being, and it may undermine the process of healing from war-related trauma and grief. Multilevel interventions that target ongoing stressors such as family violence and poverty may significantly enhance the effectiveness of MHPSS programming.
The salience of daily stressors may also explain the lack of more consistent benefits of MHPSS programs for children and youth. As my colleague Mark Jordans and I discussed in a recent paper, there is compelling evidence that the mental health of war-affected children is powerfully influenced ("mediated") by their family environment. In several studies, harsh or otherwise impaired parenting was powerfully related to distress among children in war-affected communities. MHPSS interventions for refugee and other conflict-affected children could potentially strengthen their impact by addressing the family environment, for example by supporting parents in dealing with their own distress and the stress of parenting in extremely tough circumstances. It may be that broader ecological interventions that reduce ongoing threats to children's mental health and psychosocial development (e.g., harsh parenting, exploitative and unsafe child labor, family poverty, lack of access to schools), while also strengthening key protective resources will lead to greater and more enduring effects.
A FEW FINAL THOUGHTS
1) The evidence I have discussed in this post concerns only interventions studied using randomized control trials, which are generally costly and resource-intensive. It's quite possible that other interventions, using other research designs, have had significant and lasting effects not captured in the Humanitarian Evidence Programme's systematic review. It's also possible that culturally specific healing rituals and protective resources (e.g., spiritual practices and communities of faith) that have not been subjected to rigorous evaluation have nonetheless had meaningful effects on the wellbeing of survivors of humanitarian crises.
2) Although several studies, with children and adults, have demonstrated large effects on reducing distress, none of these interventions has yet been brought to scale. As I discussed in a recent post, one reason may be an over-reliance on efficacy studies—highly resourced, intensive studies designed to assess the impact of interventions implemented under ideal conditions (e.g., intensive training and supervision of implementation staff, frequent on-site monitoring of program sessions by study personnel to ensure fidelity). Unfortunately, in the lower-resourced real world of everyday practice in humanitarian settings, we seldom get to implement interventions under ideal conditions. If we wish to create genuinely scalable programs, we also need to test their effectiveness under real world conditions, so that findings can be replicated in everyday practice.
3) The Humanitarian Evidence Programme report is focused exclusively on MHPSS interventions in low- and middle-income countries. Its findings do not speak to the effectiveness of interventions with refugees and asylum seekers, or survivors of natural disasters, in high-income countries.
4) Finally, it's imperative to advocate for an end to the violence that shatters so many lives and upends the worlds of children, their families, and their communities. In an excellent study by Alastair Ager and his colleagues, the normalization of everyday life in post-conflict Northern Uganda had by far the largest positive impact on improving children's well-being, with the authors' psychosocial intervention layering a modest additional improvement on top of those gains. Paraphrasing the late Salvadoran psychologist Ignacio Martín Baró, if we only treat distress without advocating for an end to the conditions that give rise to it, we will have no shortage of people in need of assistance.
Bangpan, M., Dickson, K., Felix, L. and Chiumento, A. (2017). The impact of mental health and psychosocial support interventions on people affected by humanitarian emergencies: A systematic review . Humanitarian Evidence Programme. Oxford: Oxfam GB.