Remember me
PERSONAL REFLECTION
Year : 2023 | Volume
: 21
| Issue : 1 | Page : 72-75
How Process Matters in Strengthening MHPSS: A Reflection
Michael G Wessells
Columbia University, Beaverdam, Virginia, USA
Correspondence Address:
PhD Michael G Wessells
Columbia University, 17028 Little River Dr, Beaverdam, VA
USA
Source of Support: None, Conflict of Interest: None
DOI: 10.4103/intv.intv_5_23
In developing the IASC Guidelines on Mental Health and Psychosocial Support in Emergency Settings, attention to social process was key for success. In retrospect, humility was crucial for reflecting on one’s own dogmas, opening up to different points of view and avoiding ideological fixity and unproductive debates. Inclusivity was the key for enabling learning from diverse perspectives and areas of expertise, drawing on understandings from different countries and developing richly contextual approaches. Effective leadership from Mark van Ommeren and participating agencies enabled a highly collaborative, transformative process. As the developing mental health and psychosocial support (MHPSS) field has become institutionalized and respected for its importance, expertise and expanding evidence base, increased attention to the process is needed. Key process considerations at present include power sharing with local people, listening to and co-learning with affected people and collective critical reflection, including on issues of process and relationships with local people. Greater attention to process can help to complement needed technical approaches, avoid unintended harm and enable more contextual, effective and sustainable humanitarian action. With attention to both technical aspects and human processes, the field of MHPSS can develop and implement comprehensive approaches and make its greatest contributions to affected people.
Keywords: co-learning, holistic approach, humility, inclusivity, leadership, listening, power sharing, process
It is an honour to reflect on the 2008 Intervention paper that Mark van Ommeren and I co-authored (Wessells & van Ommeren, 2008) and that outlined the need for the IASC Guidelines on Mental Health and Psychosocial Support in Emergency Settings ((2007); hereafter referred to as the IASC Guidelines), its structure and contents and the process for their development.
I want to reflect on the importance of process and how increased attention to process is needed at present to address the diverse challenges that mental health and psychosocial support (MHPSS) work faces in humanitarian settings. The first section of the paper looks back on key aspects of the process used in developing the IASC Guidelines. Bringing these process reflections forward, the second section reflects on some of the current social process issues that need to be addressed. To maintain a reflective style, the paper uses references sparingly. Although the reflections are my own, my views have been immeasurably enriched by many people, especially the members of the Task Force that developed the IASC Guidelines and also community people in different regions.
Looking Back
A key theme of our 2008 paper was that the process was no less important than the content of the guidelines. In fact, the process and content were inextricably interconnected. The collective processes of opening up to diverse views, developing and owning a shared vision of what comprehensive response entails, exploring the ethical complexities inherent in our work, and focusing on practical issues where we found the greatest levels of agreement were essential for the development of the IASC Guidelines and also for our spirit of collective ownership and our desire to fully implement them. As a team, we reflected on our dogmas and avoided the polarisation that had been prominent in the field. In learning from each other, we acquired new relationships with colleagues who had diverse approaches and expertise in different sectors and to whom we could look for advice. Feeling transformed by our group learning, we became infused with the spirit of learning, collaborating and looking to the broader good that is foundational for comprehensive MHPSS.
The three aspects of the process − humility, inclusivity and leadership − have become even more salient to me years later. Humility was crucial for reflecting on one’s own dogmas, opening up to different points of view and avoiding the ideological fixity and debates that had hampered previous inter-agency discussions. As different Task Force members modelled humility and spoke authentically about their dogmas, the group developed a spirit of critical reflection and an orientation towards deeper listening and co-learning from each other that ignited a collective desire for a collaborative, multi-sectoral approach.
Inclusivity was key for enabling learning from diverse perspectives and areas of expertise and developing richly contextual approaches while avoiding a discriminatory pattern of excluding low- and middle-income countries (LMIC). The Task Force took inclusivity seriously, although the pressures of time and budget were limiting factors. The Task Force deliberately sought to include psychologists, psychiatrists, social workers and specialists from other sectors of humanitarian assistance. Also, participating agencies were invited to identify talented professionals from LMIC settings as their representatives. To obtain significant feedback from MHPSS workers in many countries that could help guide revision of drafts of the guidelines, multiple drafts were circulated in English, French, Spanish and Arabic (to a lesser extent) with invitations to give input into the process. This arduous process proved valuable in enabling practitioner’s voices and inputs from different regions, including countries where the most humanitarian emergencies occurred, as well as adapting the guidelines to diverse contexts. This review process also enabled wider receptivity to and even ownership of the guidelines, which supported their subsequent dissemination and use. In addition, with support from IRC, a consultation in Geneva enabled learning from practitioners from around the world, including from LMIC settings. A second consultation in New York engaged diverse US actors, including academicians, researchers and practitioners who worked primarily on traumatic stress. It was recognized, however, that these efforts were incomplete and far from ideal.
Effective leadership was crucial for the successful work of the Task Force. Mark van Ommeren’s leadership was remarkably effective at multiple stages. Mark helped set the stage at WHO and in inter-agency discussions for the development of the guidelines. He played a key role in enabling the group process described above. It was inspiring to see the WHO Co-Chair of the Task Force invite everyone to be self-critical of their dogmas and to learn together in new ways. Mark’s introduction of key ideas such as the composite term “mental health and psychosocial support” and the intervention pyramid were carefully timed and done in a manner that built upon the insights of diverse Task Force members. When discussions drifted towards ideological positions or areas where no consensus existed, Mark patiently brought us back to practical, consensus points. Importantly, leadership was very much shared within the group. The fact that various Task Force members and agencies took the lead in developing particular action sheets was enormously valuable in developing broad, technically accurate guidelines and enabling collective ownership for them.
Looking ForwardThese points about the importance of process continue to be highly relevant today, even as MHPSS has come more to the forefront and is an integral part of humanitarian assistance. To see this, it is valuable to touch on some of the main changes that have occurred in the field of MHPSS since 2008.
A Still Young and Developing MHPSS Field
Perhaps the biggest change since 2008 is the increasing recognition of the importance of MHPSS and its institutionalisation and legitimacy as a fixture within the humanitarian system. This change likely owes, in part, to the presence and use of the IASC Guidelines, which remain highly pertinent today. This change also reflects the efforts of the IASC MHPSS Reference Group, which has worked diligently and effectively to enable use of the IASC Guidelines, integrate MHPSS into the cluster system, strengthen coordination and an intersectoral approach via Technical Working Groups in diverse humanitarian settings, and develop an extensive array of tools that support effective MHPSS (see mhpss.net). The increased prioritisation and legitimacy of MHPSS are evident also in the enshrinement of MHPSS and aspects of the IASC Guidelines in the international standards on child protection, gender-based violence and education, among others. Within the UN system, high-level recognition of the importance of MHPSS and its intersectoral impact is increasingly visible in actions such as the call by the UN Secretary-General for the integration of MHPSS into peacebuilding efforts (UNGA, 2020).
The stature and influence of MHPSS have also been enabled by a significant upsurge in research and attention to evidence-based practice. To be sure, the research is still in its formative stages and has been stronger on the side of mental health and clinical disorders than it has been in regard to psychosocial well-being. Nevertheless, it has likely helped to mature the sector and garner the attention of donors, many of whom have woven MHPSS into their funding portfolios.
Events beyond the sector have also contributed to the prioritisation of mental health and psychosocial well-being. The COVID-19 pandemic, which affected the mental health and psychosocial well-being of very large numbers of health workers and ordinary citizens, brought home to nearly everyone, the importance of MHPSS. Public awareness of the necessity of prioritizing MHPSS has also grown as celebrities such as Naomi Osaka have openly discussed their own mental health struggles, which is likely helping to reduce stigma.
As a result of these and other developments, more actors are getting involved in organising or providing MHPSS, and MHPSS work is being done in diverse sectors and regions, including by talented practitioners from LMIC settings. Together with the unprecedented level of global interest in mental health, including by donors, these changes are promising for the future development of the field.
At this juncture, however, the development of the MHPSS field is probably occurring faster in the technical arena than in regard to other aspects. Below, I suggest that the technical and funding improvements that are occurring should be complemented by process improvements.
Process Issues that Warrant Attention
Among the many process-related challenges to the field of MHPSS, four seem to be particularly prominent.
Power Sharing
Structural power asymmetry is in many respects built into the humanitarian system, making it important to use a social justice lens in one’s humanitarian work. Although the humanitarian system includes an increasing number of actors from LMIC countries, it is mostly Western countries–entities such as NGOs and research institutions, and donors–who are the centres of power. Both humanitarian funding and knowledge flow mainly from countries in the global North, where people and agencies make the key decisions about funding, which programmes and research approaches are indicated, and which standards to follow. Although the development process that led to the IASC Guidelines took inclusivity seriously, it, too, embodied the power asymmetry under discussion.
This privileging of Western knowledge and actors can seem ‘natural’ since it has been in place for so long. Nevertheless, this power asymmetry, which has resonances with colonialism, causes harm by marginalising LMIC actors and undermining the dignity and agency of people affected by humanitarian crises. Without greater power sharing, efforts towards inclusivity will be quite limited, perhaps even tokenistic.
The privileging of mostly Western actors and institutions, including the UN and other humanitarian agencies, is slowly beginning to change. For example, UNHCR (2022) has enabled a refugee-led approach, and grassroots-led work on MHPSS is springing up in multiple LMIC countries such as Colombia, Lebanon, Philippines and Uganda, among many others.
The increased power sharing is needed not only between outside and local actors but also within affected societies and localities. Following a localization agenda, some donors attempt to enable power sharing by transferring funds to a national government, which then makes key decisions about how to provide humanitarian aid. Although this approach has laudable intentions, it overlooks the fact that every country, province, city, town or village has an existing power structure that privileges some people and marginalises others, such as people with disabilities, people who identify as LGBTQIA+, youth and women, among others. If strategies such as localization benefit elites while marginalising particular vulnerable groups or people, the resulting injustice will likely cause harm that could offset the benefits of the MHPSS interventions and actions.
Listening
The paucity of open listening by humanitarian actors to emergency-affected people is not a new problem (Anderson et al., 2012). The problem arises not only from the urgency of the needs and the demand for rapid humanitarian action but also from excessive reliance on an expert-driven approach. In this approach, a well-educated specialist − typically a Westerner − leads an assessment, guides programme design based on mostly Western knowledge, and leads or supports the programme’s implementation and evaluation.
Although technical expertise is highly valuable, an overemphasis on expertise can shade into a technocratic approach that is short on humility and places outside experts in the driver’s seat while relegating local people to the status of implementing partners or beneficiaries. A strictly technical mindset can narrow the search for information to the technical area of one’s training and focus on the preconceived problems one was hired to analyze. A strict technical focus on problems such as trauma, sexual violence, or separated children entails the use of particular protocols and technical approaches that are intended to enable good decision-making and effective, ethical practice. Too often, however, these protocols and technical approaches leave little space for discussions in which affected people share their own views of how they have been affected or what is most valuable in helping people. In addition to weakening the survivors’ sense of agency and dignity, expert-driven and focused interactions can tacitly communicate that affected people are not worth listening to since they lack relevant technical expertise. Excessive focus on expert advice and leadership can also undermine the agency and dignity that are at the heart of well-being.
Co-learning
The usual assumption of experts and the agencies that employ them is that experts will share the latest scientific knowledge with workers in LMIC settings and will use the knowledge to support evidence-based practice. Although affected communities often need outside knowledge and approach, the transfer of knowledge is frequently done in a unidirectional manner. For example, a Western-derived therapeutic approach that has been tested empirically and found to be effective in Western contexts may be lightly adapted to and used in LMIC contexts. This one-way transfer continues the privileging of Western knowledge and practice, and it may fail or only partially develop the richly contextual approach that contributes to programme effectiveness, uptake and sustainability. Because the approach makes little or no effort to test empirically the effectiveness of approaches that originated in LMIC settings, it is less likely that local processes of healing, social support, social cohesion and communicating key messages will be included or that they will be tested, learned from and potentially used in other affected contexts.
Like the expert-driven approach, this unidirectional flow of knowledge mistakenly assumes that people from Western societies have relatively little to learn from people in LMIC settings. In fact, local people may know a lot about the context − much more than an outside expert would likely know − and the local resources for supporting people’s mental health and psychosocial well-being. Understanding the socio-cultural context, they may, for example, be attuned to the stigma that can result from speaking of “mental health and psychosocial support”, and they may be able to educate us about local idioms of distress, factors that contribute to suicide, and the effects of long-term discrimination and structural determinants of their well-being. An axiom of effective programming is to build upon what is already there. If we fail to learn about cultural understandings and practices, local networks of support and other local resources, we will not be in a good position to build upon what is already there.
Further, local people can often teach outside practitioners about how to do things like achieving a holistic approach. For example, national and local MHPSS practitioners in Sri Lanka have moved towards the holistic approach envisioned in the IASC Guidelines in a manner that is seldom achieved by international agencies working in a badly fragmented humanitarian system. The need for a holistic approach was evident in Sri Lanka during its horrendous armed conflict and the 2004 Asian tsunami, which led many agencies to focus on trauma and therapeutic interventions that were done in a vertical manner targeted at particular sub-groups. Over time, however, Sri Lankan MHPSS workers moved towards a more holistic approach that recognised the importance of the social and structural conditions of living and attended to problems such as poverty, which undermined women’s ability to cope (Galappatti, 2015). Therapy continued to be a priority for people who needed specialised care, yet the broadening of the approach made it possible to support a much wider array of affected people. Here is a case in which we should learn from people in Sri Lanka about how to move from a more specialist, therapeutic approach to a wider, holistic approach that is more consistent with the IASC Guidelines. For these and other reasons, it is important to engage affected people in a spirit and process of co-learning.
Collective Critical Reflection
The critical reflection that was key in the development of the IASC Guidelines remains important today since MHPSS work in humanitarian settings is complex, dynamic and evolving. Without critical reflection, workers may be less likely to examine their own assumptions and approaches, some of which may be limited or cause unintended harm, or to forge new pathways and approaches that can strengthen MHPSS practice.
At present, there are strong pressures from donors, standard bearers and researchers for evidence-based intervention, the development and use of packages that can be taken to scale rapidly, and technical capacity building for MHPSS efforts in LMIC countries. These expert-oriented approaches can have more positive effects and can avoid unintended negative effects if they are coupled with collective critical reflection and attention to process issues. This reflection should be based on humility, critical thinking amidst complexity and a willingness to try and test out approaches − including local approaches − that are a good fit for the context. A priority, then, is to create spaces for critical reflection, affording both international and local practitioners permission to step back, think in new ways and intermix action and reflection. If this approach seems too slow, steps should be taken collectively to enable a good fit for different phases of emergencies, which are increasingly long-term.
ConclusionThe severity and pervasiveness of MHPSS issues in humanitarian settings require the use of a holistic approach to addressing them. A holistic approach will include careful attention to both the technical and process aspects of humanitarian action, as human well-being is affected not only by the technical quality of the assistance provided but also by the way in which it is done. Greater attention to process can help to complement much-needed technical approaches, avoid unintended harm, and enable more contextual, effective and sustainable humanitarian action by MHPSS workers. If steps are taken to enable ongoing critical reflection and increased attention to power sharing, listening and co-learning, the MHPSS field will be better able to achieve its fullest potential for supporting emergency-affected people in their hour of greatest need.
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Conflicts of interest
There are no conflicts of interest.
References
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