1 |1 | IASC Guidelines " A significant gap has been the absence of a multi-sectoral, inter-agency framework that enables coordination, identifies useful practices, flags harmful practices and clarifies how different approaches to mental health and psychosocial support complement one another."

2 |2 | Brief orientation on the IASC Guidelines on Mental health and Psychosocial Support in Emergencies By Mark van Ommeren, WHO Geneva and Amanda Melville, Ramallah 10 Feb 2009

3 |3 | Introductions and agenda Handouts –Brochure with matrix –Print out of Field Use Version –Full Guidelines on CD ROM (explain) –True False Exercise Local expertise Personal thoughts

4 |4 | IASC Task Force: UN and non-UN agencies wrote Guidelines 20.INEE 21.IRC 22.MdM-E 23.Mercy Corps 24.MSF-H 25.Oxfam GB 26.RET 27.SC/UK 28.SC/USA 1.ICVA 2.IFRC 3.Interaction 4.IOM 5.OCHA 6.UNFPA 7.UNHCR 8.UNICEF 9.WFP 10.WHO 11.ACF 12.Am. Red Cross 13.ACT International 14.Action Aid International 15.CARE Austria 16.CCF 17.HealthNet TPO 18.IMC 19.ICMC Ref Group now also has: 29.CARE Int. 30. Ch of Sweden 31. COOPI 32.GP-SI 33.RedR 34.REPSSI 35.TdH 36.UNRWA 37.World Vision

5 |5 | Exercise 1: First reaction (1 minute) Reflect on experiences that you had or aware of related to mental health and psychosocial support during and after emergencies. Reflect on the following question. Is there a potential need for applying here internationally endorsed inter-agency mental health and psychosocial support guidelines?

6 |6 | Some typical answers to this exercise are Inter-agency guidelines are needed but –Should be culturally sensitive/adaptable –Should take local situation, capacities and resources into account –Should cover/not cover/ go beyond posttraumatic stress disorder (PTSD) –Should cover staff welfare –Should give advice on how to avoid harmful interventions and 'parachuting' foreign clinicians –Should discuss coordination

7 |7 | Inclusive framework: mental health and psychosocial support covers both (a)protecting or promoting psychosocial well-being and/or (b) preventing or treating mental disorder. PS MH

8 |8 | On problems and resources - Emergencies erode normally protective supports and increase risks for a range of problems - Most people have some access to resources (helpers, beliefs) that can be supportive and a very effective way of helping them is to build on existing social support networks (e.g. supporting parents/teachers, getting isolated elderly into community activities)

9 |9 | Diverse needs in midst of emergencies pre-existing social problems –E.g. marginalization emergency-induced social problems – E.g. family separations, loss of jobs, protection threats pre-existing psychological/psychiatric problems – E.g. psychosis, severe alcohol use, depression emergency-induced psychological/psychiatric problems –E.g. normal fear (past, present, future), depression, PTSD humanitarian aid-induced problems –E.g. conflict between communities, anxiety about lack of information on distributions,

10 | Core Principles Human rights and equity Participation Do No Harm Building on available resources and capacities Integrated support systems Multi-layered supports

11 | 11 Matrix of Mental Health and Psychosocial Support: All Have Impact on Protecting Well-being 1.Coordination 2.Assessment, monitoring and evaluation 3.Protection and human rights standards 4.Human resources 5.Community mobilisation and support 6.Health services 7.Education 8.Dissemination of information 9.Food security and nutrition 10.Shelter and site planning 11.Water and sanitation

12 | 12 Specialised services Focused, non-specialised supports Social and psychological considerations in basic services and security Community and family supports What %?

13 | Level 1: Social and Psychological Considerations in Basic Services and Security All members of the community have responsibility to ensure there is a suitable environment for psychosocial development. These activities help to establish a suitable environment to protect and promote psychosocial healing and well-being. Usually these programmes are conducted by other organisations or under an existing sector Psychosocial and mental health programmes should advocate for ensuring these basic needs are met cooperate with sectoral programmes to ensure that are implemented in a way that supports psychosocial development and healing

14 | Level 1: Social and Psychological Considerations in Basic Services and Security Document impact of lack of services and security on MHPS wellbeing and use this for advocacy For children, advocate for the protection of children from violence, abuse and exploitation, the promotion of family unity, re-establishing safe and supportive education Advocate for delivery of humanitarian assistance in a manner that promotes well-being Work to promote ways of delivering aid that promote self-reliance and dignity Facilitate community involvement in decision-making and assistance Disseminate essential information to affected populations on situation and emergency response

15 | Level 2: Community and Family Supports Support play, art, recreational and sporting activities Provide structured groups activities for expression and the development of life skills and coping mechanisms Support children and youth friendly spaces/environments Promote meaningful opportunities to participate in rebuilding society Provide information on positive coping mechanisms Activities that facilitate the inclusion of isolated individuals (orphans, widows, widowers, elderly people, people with severe mental disorders or disabilities or those without their families) into social networks;

16 | Level 2 (cont’d) Strengthening the family: –Provide culturally appropriate guidance on how parents and family members can help children –Support parents and families to cope with their own difficulties –Support and facilitate the establishment of parent groups/committees –Early childhood stimulation (with nutrition) –Informal family visits for caregivers in need of extra support –Support family access to basic services

17 | Level 2 (cont’d) Strengthening community supports: –Helping caregivers and educators to better cope and to support children –Strengthen community based supports for adult caregivers –Strengthen child-to-child or youth support –Resumption of cultural and spiritual activities, including appropriate grieving rituals –Strengthening social networks –teacher training on psychosocial care and support –Group discussions on how the community may help at-risk groups identified in the assessment as needing protection and support

18 | Level 3: Focused Supports For people who are: –struggling to cope within their existing care network –Not progressing in terms of their development –Unable to function as well as their peers –In need of activities that address their psychosocial needs more directly

19 | Level 3 (cont’d) Focused psychosocial support activities require trained and experienced staff Activities may include: –Case management –Family visits –Psychological first aid –Support groups –Structured play activities –Psychosocial hotlines –Non-clinical family or individual counselling (e.g. school counselling)

20 | Level 4: Specialized Services Traditional specialized healing (e.g. cleansing and purification rituals) Clinical social work or psychological treatment Psychotherapy Drug or alcohol treatment Specialised mental health care

21 | 21 Specialised services Focused, non-specialised supports Social and psychological considerations in basic services and security Community and family supports What %?

22 | 22 Multilayered support What does this exercise suggest? Need to ensure support is appropriately divided across layers with good coordination/referral E.g. not focused only at clinical level (e.g. Bosnia) or at social level (e.g. Uganda) Many of the professional animosities disappear as soon as one adopts a pyramid model of multi-layered supports with different tasks for different sectors

23 | Exercise 2: Do's and Don’t's (15 minutes) Purpose: to learn whether the contents of the IASC Guidelines are relevant to some issues of concern here in Gaza 20 minutes: Fill in the TRUE OR FALSE questionnaire together with somebody in the room who you do not know Followed by presentation on Do's and Don’t's as in the IASC Guidelines

24 | TRUE OR FALSE? It is good to provide single-session psychological debriefing for people in the general population as an early intervention It is good to organise access to a range of supports, including psychological first aid, to people in acute distress after exposure to a very stressful or traumatic event Methods from abroad are always better than local supportive practices and beliefs. It is good to learn about and, where appropriate, use local cultural practices to support local people. It is good to establish screening for people with mental disorders even without having in place appropriate and accessible services to care for identified persons. The main issue is that everybody is traumatised, It is good to use one-time, stand-alone trainings or very short trainings without follow- up to prepare people to do complex psychological interventions

25 | DO ’ sDON ’ Ts Establish one overall coordination group on mental health and psychosocial support. Do not create separate groups on mental health or on psychosocial support that do not talk or coordinate with one another. Support a coordinated response, participating in coordination meetings and adding value by complementing the work of others. Do not work in isolation or without thinking how one ’ s own work fits with that of others. Collect and analyse information to determine whether a response is needed and, if so, what kind of response. Do not conduct duplicate assessments or accept preliminary data in an uncritical manner.

26 | DO ’ s DON’Ts Tailor assessment tools to the local context. Do not use assessment tools not validated in the local, emergency- affected context. Recognise that people are affected by emergencies in different ways. More resilient people may function well, whereas others may be severely affected and may need specialised supports. Do not assume that everyone in an emergency is traumatised or that people who appear resilient need no support. Ask questions in the local language(s) and in a safe, supportive manner that respects confidentiality. Do not duplicate assessments or ask very distressing questions without providing follow-up support.

27 | DO ’ s DON’Ts Pay attention to gender differences.Do not assume that emergencies affect men and women (or boys and girls) in exactly the same way, or that programmes designed for men will be of equal help or accessibility for women. Check references in recruiting staff and volunteers and build the capacity of new personnel from the local and/or affected community. Do not use recruiting practices that severely weaken existing local structures. After trainings on mental health and psychosocial support, provide follow-up supervision and monitoring to ensure that interventions are implemented correctly. Do not use one-time, stand-alone trainings or very short trainings without follow-up if preparing people to perform complex psychological interventions.

28 | DO’s DON’Ts Facilitate the development of community- owned, managed and run programmes Do not use a charity model that treats people in the community mainly as beneficiaries of services. Build local capacities, supporting self-help and strengthening the resources already present in affected groups. Do not organise supports that undermine or ignore local responsibilities and capacities. Learn about and, where appropriate, use local cultural practices to support local people. Do not assume that all local cultural practices are helpful or that all local people are supportive of particular practices.

29 | DO’s DON’Ts Use methods from outside the culture where it is appropriate to do so. Do not assume that methods from abroad are necessarily better or impose them on local people in ways that marginalise local supportive practices and beliefs. Build government capacities and integrate mental health care for emergency survivors in general health services and, if available, in community mental health services. Do not create parallel mental health services for specific sub-populations. Organise access to a range of supports, including psychological first aid, to people in acute distress after exposure to an extreme stressor. Do not provide one-off, single-session psychological debriefing for people in the general population as an early intervention after exposure to conflict or natural disaster.

30 | DO’sDON’Ts Train and supervise primary/general health care workers in good prescription practices and in basic psychological support. Do not provide psychotropic medication or psychological support without training and supervision. Use basic medications that are on the essential drug list of the country. Do not introduce new, branded medications in contexts where such medications are not widely used. Establish effective systems for referring and supporting severely affected people. Do not establish screening for people with mental disorders without having in place appropriate and accessible services to care for identified persons.

31 | DO’sDON’Ts Develop locally appropriate care solutions for people at risk of being institutionalised. Do not institutionalise people (unless an institution is temporarily an indisputable last resort for basic care and protection). Use agency communication officers to promote two-way communication with the affected population as well as with the outside world. Do not use agency communication officers to communicate only with the outside world. Use channels such as the media to provide accurate information that reduces stress and enables people to access humanitarian services. Do not create or show media images that sensationalise people ’ s suffering or put people at risk.

32 | Seek to integrate psychosocial considerations as relevant into all sectors of humanitarian assistance. Do not focus solely on clinical and counselling activities in the absence of a multi-sectoral response. DO'SDON'TS Involve community members in supporting one other Do not assume that people are too exhausted and busy to support one other.

33 | Psychological debriefing? It most probably does not prevent mental health problems (general distress, depression, PTSD etc) Most probably it is not harmful But... many recipients like it! As stand-alone intervention it most likely wastes resources Recommendation: No debriefing but rather psychological first aid

34 | What is psychological first aid? often mistakenly seen as a clinical or emergency psychiatric intervention. humane, supportive response to a fellow human being who is suffering and who may need support. it does not necessarily involve a discussion of the event that caused the distress. Aspects: (1) protecting (2) listening (3) identifying basic needs and ensuring they are met (4) raising social support

35 | Exercise 3: Gaza (20 minutes) Small group discussion (20 minutes) Please reflect on the following question: how can the Guidelines be used in Gaza? Come back to plenum and give a 3 sentence summary of your discussion Plenum discussion

36 | Examples from elsewhere Used for identification of gaps in Philippines Use picture version to mobilize community in Peru Influenced a lot of PS programming in Jordan Moved people beyond counselling in Kenya Adopted by 4 ministries Gov in Philippines as policy Training in Iran informed by and consistent with IASC Some donors only fund consistent with IASC Guidelines Highlight importance of engaging with unusual sectors on MHPSS

37 | Mapping MHPSS using guideline matrix Complete matrix: each group completes one page

38 | Key messages IASC Guidelines provide a common framework and language to communicate and coordinate with one other during large crises There is substantial technical know how on how to meaningfully reduce suffering and this involves different types of complimentary supports Using them effectively must be an ongoing process involving multiple humanitarian actors