MHPSS and protection outcomes
Why joint action to improve mental health and psychosocial
wellbeing of people affected by conflict, violence and
disasters should be a priority for all protection actors
Sarah Harrison, Fahmy Hanna, Peter Ventevogel,
Nancy Polutan-Teulieres, William S. Chemaly
Policy Discussion Paper – September 2020
Introduction
This year over 100 million people were in need of protection assistance
due to conflict, violence, epidemics and climate-related disasters, or a mix
This paper aims to
of all three.1 People are affected in different ways: many have their rights
provide coordinators
abused, their lifestyle and traditions threatened or destroyed, millions
and actors in Protection are uprooted from their homes, lose their families, communities, jobs and
Clusters including its safety nets, and have their resilience tested to its limits.
Areas of Responsibility
and other areas These life changing events have a monumental impact on people’s mental
of expertise with health. One in five people living in areas affected by violence and conflict
essential information experience significant mental health conditions2 which is three times the
global estimates for populations not affected by conflict.3
on Mental Health and
Psychosocial Support Over the last decade, supporting people’s mental health and psychosocial
(MHPSS) as a key wellbeing has gained increasing recognition as a necessary and important
protection concern. part of humanitarian response. This recognition has been largely
The central tenet is that shaped by guidance4 that makes clear that effective MHPSS requires a
stronger engagement collaborative approach between multiple humanitarian disciplines.5
of protection
However, in practice, delivery of MHPSS in emergencies remains
actors with MHPSS concentrated within health, child protection, gender-based violence and
strengthens the overall mine action programmes. A closer engagement of all protection actors
protection response. and other humanitarian sectors on MHPSS, would make MHPSS more
effective and the protection response more comprehensive and equitable.
MHPSS and protection outcomes: policy discussion paper – September 2020 | 1
Protection clusters should strengthen their engagement
in MHPSS work to ensure holistic MHPSS services and KEY
deliver a stronger protection response.
MESSAGES
Improve MHPSS services to reach all
1 affected population groups, with particular
attention to cross-cutting issues and
continuity of care across the lifespan.
Include MHPSS within protection Advocate for MHPSS as a cross-cutting
2 work, particularly within programming
5 issue in the humanitarian response and
related to community-based protection, in the humanitarian programme cycle
communication with communities, (and include MHPSS in Humanitarian
accountability to affected populations and Response Plans and Humanitarian Needs
when using participatory and age, gender Overviews).
and diversity approaches. Encourage the
use of MHPSS outcome indicators within Make MHPSS a standing item on the
protection programmes. 6 agenda of protection cluster meetings and
inter-sectoral coordination meetings.
Promote the work and encourage further
3 scale up of Protection Areas of Responsibility
Support the creation or functioning of a
(AoRs) that have systematically incorporated 7 cross-sectoral MHPSS Technical Working
MHPSS within their programming - notably
Child Protection, GBV and Mine Action. Group.
Promote inclusion of MHPSS in protection
4 case management for at risk individuals
and families in humanitarian settings.
Case managers must be trained in MHPSS
skills such as psychological first aid, active
listening, problem solving, basic psychological
support, advocacy on behalf of their clients,
referrals, strength-based approaches and
accompaniment of at-risk persons.
1
UNOCHA (2020). Global Humanitarian Overview 2020.
https://hum-insight.info/
2
Charlson, F., et al. (2019). New WHO prevalence estimates of mental disorders in conflict settings: a systematic review and meta-
analysis. The Lancet, 394(10194), 240-248.
3
Vos, T., e al. (2017). Global, regional, and national incidence, prevalence, and years lived with disability for 328 diseases and injuries for
195 countries, 1990–2016: a systematic analysis for the Global Burden of Disease Study 2016. The Lancet, 390(10100), 1211-1259.
4
IASC (2007). Guidelines on Mental Health and Psychosocial Support in Emergency Settings. https://interagencystandingcommittee.org/
mental-health-and-psychosocial-support-emergency-settings-0/documents-public/iasc-guidelines-mental
5
Summary Record, IASC Principals meeting, 5 December 2019. https://interagencystandingcommittee.org/inter-agency-standing-
committee/summary-record-iasc-principals-meeting-5-december-2019
2 | MHPSS and protection outcomes: policy discussion paper – September 2020
What is MHPSS?
The widely used acronym ‘MHPSS’ refers to any type of support that aims to protect or promote
psychosocial well-being or prevent or treat mental health conditions.
MHPSS interventions should be implemented and addressed in programmes for health,
protection, education, nutrition, and camp coordination & camp management.
Within Protection work, MHPSS should be included through the various areas of expertise
including when addressing human right abuses, assisting victims of violence and supporting their
families, delivering community-based protection, and in programming on child protection, gender
based violence, persons with disability, older people, mine action, and trafficking in persons.
The term ‘MHPSS problems’ may cover a wide range of issues including social problems,
emotional distress, common mental conditions (such as depression and anxiety disorders), severe
mental health conditions (such as psychosis), alcohol and substance abuse, and intellectual,
developmental or cognitive disabilities.6
The delivery of MHPSS activities is often represented in a pyramid of multi-layered services and
support. See figure 1.
Figure 1 | MULTILAYERED MHPSS SERVICES AND SUPPORTS
1. Clinical mental
health services
2. Focused
non-specialized
psychosocial support
3. Strengthening
community and
family supports
4. Integrating social and
psychological considerations
into provision of basic
services and security
Layer 4 Layer 2
Clinical mental health and psychosocial services for Strengthening community and family support through
those with severe symptoms or whose intolerable promotion of activities that foster social cohesion and
suffering rendering them unable to carry out basic daily the restoration or development of community-based
functions. Such Interventions are usually led by mental mechanisms to protect and support individuals using
health professionals but can also be led by specialists in participatory approaches.
social work.
Layer 3 Layer 1
Provision of focused psychosocial support through Provision of basic services and security in a manner
individual, family or group interventions to provide that protects the dignity of all people, including those
emotional and practical support to those who find who are particularly marginalized or isolated and who
it difficult to cope within their own support network. may face barriers to accessing services and deliver
Health, education, community-based protection or child the response in a participatory, rights-based way. The
protection workers usually deliver such support, after objectives of protection mainstreaming are strongly
training and with ongoing supervision. aligned to this layer.
(Adapted from IASC Guidelines in Mental Health and Psychosocial Support in Emergency Settings, 2007)
MHPSS and protection outcomes: policy discussion paper – September 2020 | 3
Interaction between protection risks and MHPSS issues
There is a bidirectional relation between MHPSS issues and protection risks.
ĥ Conflicts, disasters and violence induce high levels of psychological distress due to direct
human rights violations including torture, rape and other forms of gender-based violence,
and due to losses of loved ones, homes, traditions and livelihoods.
ĥ There can be a correlation between depression and substance abuse, particularly alcohol
consumption and an increase in Intimate Partner Violence. Youth, with mental health issues,
are at greater risk for abuse and exploitation. When parents suffer from depression, they are
less likely to take good care of their children.
ĥ In emergency settings, the rights of people with pre-existing mental health conditions
are often violated, even more pervasively than in stable situations. Conflicts, disasters
and violence increase protection risks of people with severe mental health conditions in
psychiatric institutions, or who are homeless or kept locked in homes including persons with
psychosocial or other disabilities.
How does MHPSS relate to the protection response?
One of the four protection principles in the Sphere Handbook is to “Assist people to recover from
the physical and psychological effects of threatened or actual violence, coercion or deliberate
deprivation”.7
This requires all humanitarian actors to pay attention to the psychological sequelae of human
rights violations.
Addressing the mental health and psychosocial consequences of conflict, violence and disasters
contributes to protection by strengthening the agency of people to effectively address their
protection issues. The capacity of people and families to take actions to claim their rights are
negatively affected by pervasive demoralisation, feelings of depression and anxiety, memories related
to past events of violence and loss, and worries about current life circumstances and the future.
Moreover, addressing the mental health consequences of forced displacement can contribute
to durable solutions. There is a bidirectional relation between mental health and the ability to
be successful in school, job and livelihoods and including MHPSS considerations in activities for
durable solutions to be more effective.
Here are some actions for Protection Clusters to ensure solid contribution of MHPSS to the
protection response:
ò Promote Protection Areas of Responsibility (AoRs) to systematically incorporate MHPSS
within their programming and actively support those who are already doing this - notably
Child Protection, GBV and Mine Action.8
ò Improve and make access to MHPSS services more equitable to all population groups,
including women, men, children, youth, older people, LGBTI persons, survivors of torture
or arbitrary detention, survivors of forced disappearance and family of disappeared,
male and female GBV survivors, people with disabilities, and people with substance
use problems.
6
Terminology in the field of MHPSS can at times be confusing because aid agencies working in education, nutrition and protection tend
to speak of ‘psychosocial wellbeing’ while health agencies tend to speak of ‘mental health’. Agencies working in disability prefer the
term psychosocial disabilities for people with chronic mental health conditions.
7
The Sphere Handbook sets humanitarian standards for rights-based delivery of services. The latest revision of The Sphere Handbook
was in 2018, and is available here: https://spherestandards.org/handbook-2018/
8
The Mine Action AoR strongly advocates that assistance to victims of mines, explosive remnants of war and improvised explosive
devices should consist of a continuum of services including mental health and psychosocial support.
4 | MHPSS and protection outcomes: policy discussion paper – September 2020
ò Support the humanitarian response to adequately meet the MHPSS needs of at-risk
groups, which frequently remain unaddressed or are referred to specialized services,
which, if they exist at all, are often focused on clinical (medical) management of
more severe mental health issues and have limited capacity and understanding of
protection violations.
ò Scale up community-based protection activities, including protection outreach
and activities aimed at reducing stigma and discrimination of marginalised groups
in communities (e.g., persons with disabilities including those with intellectual,
developmental and cognitive disabilities) to positively impact on the well-being of
affected individuals and families.
What is the link between protection mainstreaming and a
psychosocial approach?
“Protection mainstreaming” and the “psychosocial approach” (referred to as “MHPSS
mainstreaming” in some settings) are two important concepts that constitute a common ground
for holistic work on protection and MHPSS. The two concepts have clear similarities and are
aligned in recognising that to reach protection outcomes and ensure quality MHPSS programmes,
collective and holistic action is essential.
ò Alignment in objectives: The outcomes and objectives of advocating for a psychosocial
approach are the same as the objectives and desired outcomes of protection
mainstreaming. Outcomes of MHPSS activities can be community-focused and person-
focused. In table 1, this is summarized, showing how many of the outcomes of MHPSS
are strongly contributing towards collective protection outcomes.
ò Alignment in the responsibility of all clusters: The IASC MHPSS Guidelines (released
in 2007) have action sheets aimed at adopting a psychosocial approach in food security
& nutrition, WASH, shelter and site management and information, education and
communication. The Protection Cluster Mainstreaming toolkit also looks at specific role,
checklists and inputs from all other clusters.
ò Alignment in reporting approach: Protection actors report on safety, dignity and rights
and MHPSS actors report on improvements in psychosocial wellbeing and/or prevention
of further psychological distress.
Table 1 | SUMMARY OF THE COMMON FRAMEWORK
Goal: Reduced suffering and improved mental health and psychosocial well-being
Outcomes
(1) Emergency responses do not (2) People are safe, protected, (3) Family, community and
cause harm and are dignified and human rights violations social structures promote
Community-focused participatory, community are addressed the well-being and
owned and socially and development of all their
culturally acceptable members
Person-focused (4) Communities and families support (5) People with mental health and
people with mental health and psychosocial problems use appropriate
psychosocial problems focused care
Underlying core principles : 1. Human rights and equity, 2. Participation, 3. Do no harm, 4. Integrated services and supports,
5. Building on available resources and capacities, 6. Multilayered supports
Source: IASC (2018) Common Monitoring and Evaluation Framework for MHPSS programmes in emergency settings.
https://interagencystandingcommittee.org/iasc-reference-group-mental-health-and-psychosocial-support-emergency-settings/iasc-common
MHPSS and protection outcomes: policy discussion paper – September 2020 | 5
Who is responsible for MHPSS in humanitarian settings and
cluster system?
No single cluster agency or cluster is, on its own, responsible or accountable for MHPSS. It is a
shared responsibility of multiple agencies and clusters.
At the global level, the IASC MHPSS Reference Group9 is the primary platform for coordination,
operational support, policy-advocacy within the humanitarian system and the development of
technical guidance around MHPSS.
At the country level, MHPSS is not a separate cluster or a sub-cluster but relevant area of work
for various clusters, including Protection.
All humanitarian contexts (should) have an MHPSS technical working group (TWG), which serves
as a forum where agencies involved in MHPSS programming (either standalone or integrated
into their work in sectors – such as nutrition and education) can meet to discuss technical
programming issues related to the humanitarian response.
Importantly, accountability for activities remains within the respective clusters, as does reporting
on 5Ws, Humanitarian Needs Overviews and Humanitarian Response Plans. MHPSS TWGs do not
replace the role and functioning of clusters in a country, they are technical forums (similar to cash-
based programming). MHPSS TWGs are ideally co-chaired by a health agency and a protection
agency to balance diverse and complementary approaches. The exact configuration should
be decided at country-level by the involved MHPSS actors. In many country-based TWGs non-
governmental organisations play key roles.
The below diagram (figure 2) outlines the preferred structural position of an MHPSS TWG within
the coordination structures:
Figure 2 | MHPSS COORDINATION WITHIN THE HUMANITARIAN SYSTEM
Humanitarian Coordinator
Inter-Cluster Coordination Group
Health Cluster Nutrition Cluster Protection Cluster Education Cluster Camp Coordination
(with Protection Areas of Responsibility (AoRs) and Camp
• AoR Child Protection Management
• AoR GBV Cluster
• AoR Mine Action
• AoR Housing, Land, and Property
MHPSS Technical Working Group
(with focal points in relevant clusters)
9
This group has 57 member agencies. Its leadership is rotational, currently the International Federation of Red Cross and Red Crescent
Societies (IFRC) and the World Health Organization (WHO) co-chair the group.
6 | MHPSS and protection outcomes: policy discussion paper – September 2020
Recent policy developments
Good practice
example: MHPSS
“Too often we overlook one of the most important aspects Working Group in
of what helps us as humans to survive. And that is our South Sudan
state of mind. People caught in crisis do need water, food The mental health and
and shelter and other material things – but they also need psychosocial support
help to cope and recover from calamity. They need help to (MHPSS) infrastructure
restore their mental wellbeing.” in South Sudan has
– Mark Lowcock, United Nations Under-Secretary-General for Humanitarian improved. Progress is
Affairs and Emergency Relief Coordinator10 being made with building
capacity for provision
of mental health and
psychosocial support in
The relevance of mental health as a major issue within humanitarian responses is the country. The MHPSS
increasingly recognized by humanitarian actors in meetings organized in Germany, Technical Working
the UK and the Netherlands.11,12,13 Moreover, the IASC Principals in their meeting of Group collaborated and
5 December 2019 agreed to: supported the wider
ā Treat MHPSS as a cross-cutting issue that has relevance within health, network of MHPSS
protection, nutrition, education and CCCM sectors/clusters, in all stakeholders in the country
emergencies. including universities and
ā Reflect MHPSS indicators in relevant planning documents and establish relevant ministries.
dedicated budget lines, as well as specific MHPSS codes within financial Activities that have taken
tracking systems. place include nationwide
ā Support the creation and the work of country-level MHPSS Working Groups mapping of mental
in all migration, refugee and humanitarian contexts as crosscutting groups.14 health and psychosocial
The recent Global Humanitarian Response Plan for the COVID-19 pandemic, resources, trainings
contains multiple references to MHPSS throughout the document.15 Three UN on understanding the
agencies (WHO, UNICEF & UNHCR) are developing a Minimum Service Package Inter-Agency Standing
for MHPSS which will include interventions in health and protection for children Committee MHPSS
and adults. guidelines; prevention of
suicide; and understanding
MHPSS needs for people
Conclusion with a disability. The
Technical Working Group
Through closer engagement of the protection clusters and AORs with MHPSS
cooperates with Juba
experts and agencies, issues of mental health and psychosocial wellbeing can
University to set up long
gain a more prominent role in supporting people affected by crisis to address
term and short-term
their protection risks and needs. Moreover, the inclusion of MHPSS services
training programmes.
within protection programming would benefit the affected population especially
Progress is being made
in reference to community-based protection and accountability. Protection actors
to agree on using MHPSS
and coordinators should ensure that MHPSS is a standing agenda item with the
principles in religious
protection section of the Humanitarian Country’s team agenda and promote inter-
institutions.
sectoral collaboration with other actors in the protection response.
10
Remarks at the International Conference on Mental Health and Psychosocial Support in Crisis Situations, Amsterdam, 8 October 2019.
https://www.government.nl/topics/mhpss/documents/speeches/2019/10/08/speech-mark-lowcock-mhpss-conference
11
Wilton Park meeting No 1581: Dealing with the mental health needs of children and adolescents affected by conflict. 17-19 Jan 2018.
12
Federal Ministry of Economic Cooperation and Development of Germany and UNICEF ‘Rebuilding Lives: Addressing Needs, Scaling-up
and Increasing Long-term Structural MHPSS Interventions in Protracted and Post-Conflict Settings’. 4-5 July 2018.
13
Government of the Netherlands. International Conference on Mental Health and Psychosocial Support in Crisis Situations Amsterdam,
7-8 October 2019.
14
IASC Summary Record and Action Points of Principals Meeting, Geneva, 5 December 2019.
15
Global Humanitarian Response Plan COVID-19.
MHPSS and protection outcomes: policy discussion paper – September 2020 | 7
Key documents related to MHPSS
1. IASC (2007). Guidelines on Mental Health and Psychosocial Support in Emergency Settings.
2. IASC (2017). Inter-Agency Referral Guidance Note for Mental Health and Psychosocial Support in Emergency Settings.
3. IASC (2017). Common Monitoring and Evaluation Framework for MHPSS Programmes in Emergency Setting.
4. IASC Reference Group for MHPSS (2011). Mental Health and Psychosocial Support: What Should Protection Programme
Managers Know?
5. Sphere Handbook (2018).
6. International Mine Action Standards on Victim Assistance (2020 update)
7. WHO and UNHCR (2012). Assessing mental health and psychosocial needs and resources. Toolkit for humanitarian
settings.
8. Minimum Standards for Child Protection in Humanitarian Action (2019): Standard 10: Mental health and psychosocial
distress)
9. The Inter-Agency Minimum Standards for Gender-based Violence in Emergencies Programming (2019): Standard 4:
Health Care for GBV Survivors, Standard 5: Psychosocial Support, Standard 6: GBV Case Management, Standard 8:
Women’s and Girl’s Safe Spaces.
10. Mind the Mind Now (2019): Declaration of International Conference on Mental Health and Psychosocial Support in Crisis
Situations.
11. United Nations Policy Brief: COVID-19 and the Need for Action on Mental Health (2020).
IASC materials on MHPSS and COVID-19
ā IASC (2020). Interim Briefing Note Addressing Mental Health and Psychosocial Aspects of COVID-19 Outbreak.1 Provides
basic guidance on the effects of COVID-19 on mental health and psychosocial wellbeing and how to MHPSS can be
integrated in the overall COVID-19 response.
ā IASC (2020). My Hero is You, Storybook for Children on COVID-19. An illustrated book for parents, teachers and other
caregivers to explain to children in humanitarian and non-humanitarian settings what they can do keep themselves and
other safe.
ā IASC (2020). Basic Psychosocial Skills- A Guide for COVID-19 Responders.8 An illustrated book to support staff and
volunteers in the COVID-19 response in coping with the stresses of the pandemic and effectively supporting others.
ā IASC (2020) Operational considerations for multisectoral mental health and psychosocial support programmes during
the COVID-19 pandemic.1 Contains detailed guidance and tips on adapting MHPSS services in humanitarian settings.
identification and management of high-risk service users.
Where can I find out more information on MHPSS in humanitarian settings?
For more information and/ or to join the mailing list, please contact the global Co-Chairs of the IASC MHPSS
reference group:
ò Fahmy Hanna, World Health Organization: hannaf@who.int
ò Sarah Harrison, International Federation of Red Cross Red Crescent Societies: mhpss.refgroup@gmail.com.
ò www.mhpss.net – an open, global, platform for MHPSS actors. Country-level groups are activated for current
emergency contexts.
ò IASC MHPSS RG webpage under the IASC Secretariat.
Harrison, S., Hanna, F. Ventevogel, P., Polutan-Teulieres, N & Chemaly, W.S. (2020).
MHPSS and protection outcomes: Why joint action to improve mental health and
psychosocial wellbeing of people affected by conflict, violence and disasters
should be a priority for all protection actors - Policy Discussion Paper. Geneva,
Global Protection Cluster and IASC Reference Group for Mental Health and
Psychosocial Support in Emergency Settings.
For queries and comments please send an email to Global Protection Cluster (gpc@unhcr.org)
or the Reference Group for MHPSS (mhpss.refgroup@gmail.com)
8 | MHPSS and protection outcomes: policy discussion paper – September 2020
