The response of most international agencies and organisations to humanitarian crises has in recent years incorporated mental health and psychosocial support components. Most humanitarian actors consider it essential that these components, which are closely related and considered complementary, are implemented in emergencies.
Humanitarian emergencies caused by social violence, armed conflict, extreme weather events that lead to natural disasters, or epidemic outbreaks not only cause devastation in the affected areas, but also cause a large number of victims. Regardless of the nature of the crises, they often lead to major forced population displacements, which can turn in trigger social crises in the communities affected. This not only puts people's dignity at risk, but also leads to situations where rights violations can occur. However, the impact at the individual level is even greater, generating intense psychological suffering for those affected.
How humanitarian emergencies affect communities and individuals will depend, among other factors, on the type of event that has occurred. Generally speaking, their effects include social dislocation and disruption of the affected community's development projects. The functioning of social groups and the catalytic role that social networks play in the community are also disrupted. In addition, it is important to take into account the contagion of emotional suffering that occurs in a community affected by a crisis, which leads to the rapid transmission of psychological distress, anxiety and hopelessness among the collective.
At the individual level, humanitarian crises can affect people's psychological balance and even their mental health. In the case of people with a pre-existing mental health condition, there is usually an increase in symptoms or decompensation of these processes. However, there are also different biological, psychological and environmental factors that interact to cause people to develop psychological disorders or, on the contrary, to become resistant to them. Thus, although the entire population may be affected psychologically by the crisis, certain subgroups are more susceptible. These include refugees, ethnic minorities, people with chronic illnesses, people with mental health conditions, people with intellectual disabilities, elderly people, women without family support, unaccompanied minors and socially excluded groups.
Taken together, this results in a marked increase in the burden of psychological and psychosocial problems in contexts of humanitarian crises. It is difficult to quantify the extent of this, but according to data from WHO studies, cases of mental health conditions, which in normal contexts amount to between 10% and 15% of the population, often double in these humanitarian settings to 22% of the population. This represents a remarkably high prevalence of mental health conditions.
A more detailed analysis of mental health disturbances in humanitarian crisis situations shows that the most frequently encountered cases involve emotional disturbances due to the event and psychological crises due to threats to people’s survival. Situational stress arising from the difficult living conditions in these contexts is also common. However, the boundary between these understandable and often transient emotional reactions and psychological disturbance is rather blurred. The latter can be said to occur in the case of traumatic reactions to highly shocking events, in mourning reactions to the loss of loved ones, or in somatisation in the face of challenges that are difficult to cope with, among others. These conditions, which can lead to psychological breakdown, affect around 13% of the population in these scenarios.
In affected children, symptoms can range from loss of interest in play and interaction with other children, to sleep or eating disorders, or developmental regression such as nocturnal enuresis. In adolescents, loss of interest in studies and behavioural disturbances that affect the family environment can also be observed.
Of greater significance in adults are cases of depressive disorders and moderate anxiety disorders, among which panic attacks are particularly prominent. One of the most typical clinical pictures in emergency situations involves Post-Traumatic Stress Disorder (PTSD), which affects to varying degrees those who have lived experiences of high risk to physical integrity. These moderate conditions affect 4% of the population.
Difficulty coping with complex situations can in some cases also lead to substance abuse. The substance involved is mostly alcohol, due to availability and how it easy it can be to obtain alcoholic beverages. This abuse can lead to serious disruptions to relationships in the person's environment. Depending on the circumstances, there may also be consumption of other addictive substances that can be quite harmful for the user. Another highly maladaptive behaviour involves attempts at self-harm, which can be related to experiences of hopelessness on the part of the sufferer and can have devastating consequences for the person themselves and for their immediate environment.
The most worrying cases involve people who already have a mental health condition which, in the context of a humanitarian crisis, is highly likely to increase in intensity or to lead to decompensation. In addition, interruption of therapy or treatment will significantly aggravate symptoms. These conditions can affect up to 5% of the population in these contexts.
Responding to the psychosocial needs of the community, and to the individual needs of affected people, must be part of the overall intervention strategy of humanitarian actors in emergencies. The UN humanitarian agencies, with the WHO in the lead and the IASC (Inter-Agency Standing Committee), have a framework for action that groups the coverage of psychosocial and mental health needs into different categories. These levels should all be taken into account, from the most essential, which are common to the majority of the population, to the more specific, and in a complementary manner.
Therefore, prior to any intervention, it is crucial that the affected population have their basic survival needs met and protection ensured. This requires significant coordination among humanitarian agencies and organisations on the one hand, and the involvement of local authorities and international security agencies on the other.
The purpose of humanitarian interventions is primarily to ensure the survival of the population. However, survival itself is not enough, as people also need to enjoy conditions of dignity and to feel integrated into their socio-cultural environment. This is key to restoring the psychosocial well-being of the community. The aim is to maintain social organisation by re-establishing social support networks while strengthening community services. In addition, people must be given access to the aid resources deployed by humanitarian agencies. Improved psychosocial well-being is a key motivating factor for social functioning that will contribute to a more rapid exit from the humanitarian crisis situation.
At the same time, the humanitarian response aims to address the psychological impact of the humanitarian crisis on individuals and families affected. The majority of those with emotional distress benefit from interventions focused on emotional support for milder cases, and crisis intervention for more severe cases. These are provided by local humanitarian relief and response teams trained in Psychological First Aid.
Those who experience reactive psychological responses to overwhelming situations will benefit from individual counselling. Meanwhile, group interventions are helpful when it comes to building community resilience and social cohesion, which is much needed in these settings. Such interventions can be carried out by counsellors from the community who are trained in these skills. The individual interventions described so far may in certain contexts, such as armed conflict, benefit from the establishment of hotlines. Such hotlines should be set up at the outset of the humanitarian response.
Interventions for those who have experienced a mild or moderate mental health condition as a result of the impact of the humanitarian crisis often need to involve counselling, which must be delivered by mental health professionals with experience in emergencies. Those requiring additional interventions should be referred, through established referral circuits, to functioning local mental health services, or those provided by humanitarian mental health teams.
These specialised services will provide assistance to people with severe mental health conditions. This type of care endeavours to involve the affected person’s family and immediate environment. Quality interventions require the mobilisation of community resources and qualified personnel, which are often not available in emergency settings. There is unanimous agreement on the need to treat from the outset mental health issues which arise or are aggravated in these situations. Early intervention will prevent these conditions from progressing and becoming chronic, which can have a devastating impact on those affected.
Nevertheless, the mental health and psychosocial support response during a humanitarian crisis is often constrained by health systems which tend to be fragile and ill-equipped to cope with the increased needs that arise in these settings. Similarly, the reduced functionality or disruption of services can present a challenge for affected people who need them. This is compounded by a shortage of mental health professional , partly because they themselves are affected by the crisis or have to take care of their own families or suffer forced displacement. In addition, damage to or destruction of infrastructure poses a major challenge when it comes to providing care to the population, which in many cases has to be channelled through temporary structures which are set up so as to provide a partial solution to this problem.
In these circumstances, the assistance provided by international humanitarian agencies and organisations is crucial. It is imperative that the latter have the ability to provide mental health and psychosocial support in emergencies. Moreover, the assistance they provide must be planned from the outset and integrated into humanitarian field deployments. This requires teams trained in providing mental health care and psychosocial support, and the necessary expertise to ensure that interventions meet international quality standards.
As well as providing mental health and psychosocial support, the response must be complemented by strategies aimed at protecting the rights of people with mental health issues. These people are at high risk of rights violations in contexts of humanitarian crisis. Not only do they experience difficulties in caring for themselves and their families, but they also face discriminatory attitudes in many settings. They often have little access to humanitarian assistance and may even experience social stigma and rejection. They are often denied opportunities to participate fully in the community and are sometimes abused or neglected. Humanitarian organisations need to develop a course of action aimed at preventing and addressing these undesirable situations and to carry out appropriate mental health promotion at the community level.
There is now a broad consensus in the humanitarian world that mental health and psychosocial well-being are key to ensuring that people can continue to function in these demanding contexts. They are also necessary for strengthening community resilience and for the recovery of communities in crisis situations. As humanitarian organisations, we need to be much more proactive in lobbying policy makers to allocate more resources to mental health and psychosocial well-being in emergencies.