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Rebecca Horn 
Independent psychosocial specialist and Senior Research Fellow, Institute of Global Health and Development, Queen Margaret University, UK

I have been a working psychologist for more than 20 years, and since 2003 mainly in humanitarian settings with people affected by conflict, disaster and other emergencies – including the Ebola outbreak in West Africa. Over the years, the humanitarian community has learned a great deal about how such events affect the mental health and psychosocial wellbeing of those involved, and what helps them to recover. Recently I have been increasingly struck by the feeling that the lessons, so painfully learned in humanitarian settings, have not made their way into practice in western societies, including in the United Kingdom where I now live.

I first noticed this when the fatal Grenfell Tower fire happened in June 2017. In humanitarian settings, when a disaster occurs we know the response should include the participation of the affected community. This did not happen after the Grenfell Tower disaster, and over time it seemed, from media reports, their exclusion from the process added distress for those affected.

I see it again in the response from some quarters to the COVID-19 outbreak. The assumption that large proportions of our population will be ‘traumatised’ by the COVID-19 outbreak and the associated lockdown, or that there will be a ‘mental health pandemic’ to accompany the COVID-19 pandemic, just does not fit with what we know about the impact of situations such as this on mental health and psychosocial wellbeing. This may be the first time such a situation has occurred in the UK in our lifetimes, but it is not the first time it has happened. The idea that huge proportions of a population ¬– including frontline responders such as healthcare staff – will need specialist mental health support is not in line with evidence from other emergency situations.

Here, I want to apply some of what we know from humanitarian settings about mental health and psychosocial support to the COVID-19 outbreak in the UK context.

How do emergencies like the COVID-19 pandemic affect mental health?

Statistics produced by the World Health Organization, based on studies of a wide range of emergencies, suggest that while almost everybody will experience a range of difficult thoughts and feelings (including fear, grief, uncertainty, hopelessness), most people will improve over time without any expert intervention, as long as they have access to their basic needs (safety, information, food, etc.) and they remain socially connected.

In populations which experienced war or other conflict in the previous 10 years, about 13% of people developed mild forms of distress, 4% developed moderate forms, and 5% developed severe disorders. We would not expect the figures to be higher in our current situation.

What helps to protect people in emergencies from developing mental health problems?

There are ways to promote good psychosocial wellbeing and protect against mental health problems that do not require any mental health expertise. These are known as the ‘core principles’ of mental health and psychosocial support in emergencies, and they can be integrated into any type of service (such as food provision, and healthcare). These are simple and well-established yet are rarely in evidence in the UK. Let’s go through them briefly.

CORE PRINCIPLES OF MENTAL HEALTH AND PSYCHOSOCIAL SUPPORT IN EMERGENCIES

Human rights and equity: Ensure that the marginalised and most vulnerable are able to access services

Do no harm: Assess the potential impact of a response to ensure that even if it is not possible to improve the situation, the response does not make it worse. This often involves identifying those people, places, events that bring people together (‘connectors’) and those that can cause division and conflict (‘dividers’), then making sure that a service strengthens connectors and minimises dividers.

Build on available resources and capacity: Identify the strengths, resources and capacities within a community and ensure that any response or service makes use of these. Even in the worst situations, there are people with skills and capacities that can contribute to the response – and engaging this not only results in a response more likely to meet the needs of the population but also increases the sense of self-efficacy and community-efficacy. This contributes to recovery from distressing events.

Participation: Ensure that those whose lives will be affected by decisions made and actions taken play a part in the decision-making process.

Integrated support systems: ‘Stand-alone’ psychosocial/ mental health services (such as a counselling service on request) are not always helpful – for example, because people are reluctant to access them until their distress becomes severe. It is more effective to integrate psychosocial and mental health support into services that people already access, such as healthcare or schools. It can also be integrated informally into services like beauty salons or bars, with staff trained to have ‘supportive conversations’ with clients.

Multi-layered supports: We know that people will be affected differently by emergencies, based on the internal and external resources available to them. This means that different types of supports and services are required to meet the psychosocial and mental needs of a population.

The final core principle is illustrated by the Mental Health and Psychosocial Support Intervention Pyramid, which is widely used in emergency contexts.

The pyramid is intended to represent the proportion of a population who will need each type of service in order to maintain good psychosocial wellbeing and mental health. It shows that everybody affected by an emergency will need basic services and security to be available in a way which is safe, dignified and accessible to people with specific needs. If these services are not available, or are provided in a way which is unpredictable or inappropriate, distress is likely to increase.

A large proportion of the population will need additional supports to ensure that social connections and networks either remain strong or are rebuilt (if they were disrupted by the emergency). Social connections are essential for good emotional wellbeing, and they promote recovery from distressing events.

As already noted, most people affected by an emergency will experience painful feelings but will cope and recover over time if these two types of service and supports are in place. A small proportion of the population will experience higher levels of emotional distress, which they cannot manage with the normal supports, although they are still able to more or less function in their daily lives. These people can benefit from emotional supports provided by those who are not mental health specialists, but who have been trained and supervised to provide this kind of support to individuals and groups. Then there is a smaller proportion (the 5% with severe mental disorders referred to above) who need specialist mental health care.

What does this mean for supporting community mental health and psychosocial wellbeing during the COVID-19 outbreak?

The core principles described above were developed for humanitarian settings, and they have been applied in many emergencies around the world – including epidemics. People living in the global south are those most often affected by emergencies, so our learning about effects on mental health and effective responses mainly comes from those settings, but the current COVID-19 outbreak is also an emergency, and I see no reason the same would not apply in the UK or other Western societies. Some of the implications of this could be:

  • Most of us will experience painful emotions during this time – this is to be expected, and the vast majority will recover without needing any support from mental health professionals.
  • To promote good psychosocial wellbeing and mental health (and to prevent mental health problems developing), we all need:
    1. accurate, clear and consistent information, repeated and updated regularly, about the outbreak itself and how we can best take care of ourselves and each other (physically and emotionally);
    2. to be safe;
    3. to have access to basic needs (e.g. food, water, shelter, healthcare, not always available in humanitarian settings). 

What can we learn from mental health and psychosocial support in emergencies around the world?

The key take-aways from what we have learned in humanitarian settings around the world are:

  • To strengthen psychosocial wellbeing and promote good mental health, we should focus on providing the basics in a way thst strengthens relationships and enables participation.
  • If we do this, most people will experience painful feelings during the outbreak and immediately afterwards but will recover without intervention from mental health specialists.
  • Of those who do need additional support, most will benefit from evidence-based emotional support provided by non-specialists who have been trained and are supervised.
  • A small number will need specialist mental health services.
  • Those with pre-existing mental health conditions and those who are isolated or marginalised are most at risk and additional efforts should be made to enable them to get the support they need.
  • Healthcare workers and others involved in the response are under additional pressures, but the same principles apply.

This is an edited version of article that first appeared here.

Dr. Rebecca Horn is an independent psychosocial specialist working mainly in humanitarian settings with people affected by conflict and displacement.  She is also a Senior Research Fellow with the Institute of Global Health and Development, Queen Margaret University, UK.

 

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