Brief mental health interventions in conflict and emergency settings: an overview of four Médecins Sans Frontières – France programs

Mental health problems are common in humanitarian settings – both those caused by war and violence and those caused by natural disasters [1]. One of the most common diagnoses following armed conflict and natural disasters is post-traumatic stress disorder (PTSD) [2, 3]. Nonetheless, other mood and anxiety disorders are also highly prevalent [2, 4‐6]. Severe mental health problems such as psychosis are less common, and often antecedent to humanitarian emergencies, but their management in times of conflict and disaster can be difficult [7].

Given the high burden of mental health problems, provision of mental health services is an important part of an integrated package of care during humanitarian crises [8]. Nonetheless, good evidence about the most effective treatment strategies for children and adults is sparse, and current guidelines are based largely on expert opinions [9‐11]. Better evidence about the role of mental health care in humanitarian settings is needed [12]. However, carrying out clinical research in these settings can be challenging, partially because of weakened health systems and structures. Likewise, specific, targeted interventions may not be appropriate in all cultures and regions.

Since 1989, MSF France has provided psychological care to persons affected by violence and lacking medical support [13, 14], implementing mental health care programs in response to emergencies in over 40 countries on five continents worldwide. Principles of psychological first aid are used. The psychotherapeutic work that is offered through MSF programs is based on Winnicott’s therapeutic consultations model for children that we have adapted for adults and for varied cultural contexts [15, 16]. We encourage individuals (adults, or where appropriate, children) and families or dyads (mothers with their children) to externalize their emotions and fears, to share their traumas, depression and anxiety, and to cope with their stresses [16]. We take into account different social and cultural contexts, using local therapists or translators [17‐19], and we are guided by principles of psychodynamic and interpersonal psychotherapy [18, 20]. While the details of the intervention may change slightly depending on the context, the overall psychotherapeutic technique remains the same. Patients with complex mental health problems and those not in the target population of the various interventions are referred to existing local health structures designed for longer-term psychological and psychiatric care.

Given the paucity of published literature on the subject, the cross-cultural aspect of MSF mental health programming can provide important insights on responding to emergencies. Here we describe patients enrolled in 4 mental health programs in emergency contexts, their diagnoses and their clinical evolution. Some of the data have been published individually [6, 21, 22]. In the context of this synthesis, we aim to show the results of brief psychological interventions in diverse emergency contexts, from areas experiencing chronic and acute violence as well as major natural disasters. Anonymized patient data were entered into Epidata (Odense, Denmark) and analyzed with STATA 10.1 (College Station, Texas, USA). The program was authorized by local authorities and patients were informed about the use of data in research. Privacy and confidentiality of patients were ensured during the treatment and after the conduct of the analysis. This analysis met the criteria for review of program monitoring data and for exemption from the MSF Ethics Review Board.

The strength of the current overview is that it shows a straightforward model of care that has been adapted for use in a wide variety of humanitarian settings – from Latin America to the Middle East to China. Furthermore, in these diverse settings – acute conflict, chronic conflict, and post-natural disaster – the overall patient-level results were extremely satisfactory, with marked improvement of functionality and/or symptom intensity seen throughout.

On the most basic level, several lessons can be taken away from this series of programs. Most importantly, it is possible to provide high-quality mental health care in the midst of humanitarian emergencies. While this is not necessarily a new observation, many previous reports of the effectiveness of psychotherapeutic interventions have been in the setting of clinical trials, under controlled settings, and with a larger infrastructure. The data described here are simply programmatic. On one hand, this is not ideal for drawing conclusions, but on the other hand, given the large number of patients across such different settings, the strength of the results described here – under actual program conditions – underscores the importance of including this type of programming in a standard emergency response.

The clinical improvement of patients provides several learning points. First, we believe that our model of care provision is well-adapted for responding to humanitarian emergencies. Non-professionals undergo intense, short-term training on providing coping skills and brief counseling sessions. One benefit of this model is that the counselors begin their training with a high level of language skills, and often cultural competency, relevant to the populations for whom they are caring. On the other hand, the use of non-professionals as counselors creates a burden for the supervising mental health professionals, both in terms of diagnostic accuracy as well as therapeutic follow-up. It also limits the number of clinical diagnoses that are able to be cared for in one program. Nonetheless, given that a large majority of our patients suffered from a limited number of mood and anxiety disorders, the training of counselors is made easier.

The measures of outcomes described here are rudimentary – often measured as “improved”, “unchanged”, or “worsened”, and did not always correlate to quantitative measures. At the same time, given the diversity of the social and political contexts, in the absence of standardized transcultural evaluation methods, this sort of simple measurement is actually quite powerful. Using standard checklists of symptoms, mental health professionals with a variety of backgrounds and non-professional counselors were able to make judgments about patient outcomes. In these humanitarian emergencies, the first goal of our mental health programs was to improve functionality and symptoms. This high rate of symptom-based and functional improvement was seen in all of the projects described here.

Despite efforts, given the wide variety of contexts reported here, it is clear that clinical diagnoses were not completely standardized, thus limiting specific analysis of outcome by clinical diagnosis. This would be interesting to consider, particularly for post-traumatic stress disorder and other anxiety disorders, which were the most common diagnoses encountered. While our results showed good levels of clinical improvement, it would also be interesting to see if rates of response differed by age. Given the variety of different therapeutic interventions used (individual, dyad, and group therapy), and without a more structured and consistent method of assessment across contexts, we are hesitant to draw conclusions.

Lastly, it would also be interesting to consider the costs of these different interventions. Given the overall rapid improvement of patients enrolled in our programs, quantifying the financial needs for program implementation, which we imagine to be comparatively small, might provide additional impetus for the inclusion of similar programs in other humanitarian emergencies.

Standardization of data collection and evaluation methods would allow for greater comparability across different contexts. While patient care is rightfully prioritized in humanitarian settings, standardized monitoring of mental health diagnoses and outcomes would facilitate program evaluation. Additional rigorous assessments are still needed, but there appears to be an overall benefit to appropriately-targeted psychotherapy in war and other humanitarian crises [6, 12, 22, 23].

The interventions we describe here were short-term. Implementation of longer-term psychological follow-up, particularly in areas affected by chronic violence, remains challenging. In our programs, patients needing ongoing psychiatric care were referred to local health care structures and other partner organizations. While beyond the scope of this overview, and indeed beyond the scope of MSF mental health interventions, it would be interesting to further assess the psychological needs of this group of patients.

Few conclusive studies assessing the effectiveness of mental health interventions in crises have been conducted. As a result, there is an ongoing gap in the current evidence base on individual components of mental health packages as well as best therapeutic strategies for specific diagnoses in low resource settings. One such study showed positive results in the treatment of PTSD in survivors of sexual violence and could be used as a model for research [24]. Additional examples of studies which could be conducted in crises should include outcome assessments as well as quasi-experimental designs where there is a built-in comparator and cross-culturally validated assessment tool. It is important to note that ethical concerns and the need to provide treatment may preclude the use of individual randomization.

Providing mental health care services should be part of the standard response to humanitarian emergencies. Our experience in vastly different settings shows that it is both feasible and beneficial for the patients. Our model, using a variety of mental health care providers – professionals and specially-trained local counselors – allowed us to care for a large number of patients in difficult contexts.