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““Instead of viewing 

populations affected by war 

as a homogenous group, all 

of whom equally experience 

psychosocial consequences of 

war, the ‘Guidelines on Mental 

Health and Psychosocial Support in Emergency Settings’ 

recognize that programs need 

to be systematic in identifying 

particular vulnerable and 

affected populations as well 

as meeting needs shared by 

the entire community.”

September 28, 2010 

Mental Health Services During and 

After Armed Conflict: The State of 

Knowledge and Practice

Summary

•	 There is increasing recognition that the violence, displacement, disruption of communities 

and social networks, and deprivation stemming from war deeply impact the mental health 

of individuals and the social cohesion of communities. In response, donors and providers are 

creating programs for psychosocial or clinical services that seek to be culturally appropriate, 

attentive to the need to build local capacity, and sustainable.

•	 The quality and comprehensiveness of mental health programs offered in crises, however, 

generally remains mixed. Too often the programs do not sufficiently differentiate among 

widely varying individual needs or focus predominantly on either community-based interventions or the clinical needs of more severely affected people but not both. Services for people 

with more severe disabilities often replicate institutional models, and accompanying human 

rights violations, that existed in the pre-war period. The challenge of providing sound programs, moreover, is complicated by a relatively thin evidence base.

•	 In the face of these challenges, the “Guidelines on Mental Health and Psychosocial Support 

in Emergency Settings” adopted in 2007 by the Interagency Standing Committee (IASC) offer 

a promising approach. They stress understanding local context, programming that attends 

to psychosocial support needs of the entire community, meeting clinical needs of people 

with more severe conditions, and respecting human rights. Following the IASC and building 

the evidence base by assuring adequate evaluation of funded programs can help meet the 

tremendous mental health needs of suffering populations. 

Introduction

As evidence of the severe mental health consequences of war accumulates, donors, humanitarian 

and development agencies, and ministries of health have begun integrating mental health services into their health and social interventions in regions of conflict. The challenges of identifying 

priority populations, appropriate models for services, training local staff and even determining the 

relationship between community and individual needs, however, have proved daunting, especially 

given the paucity of research in the field. In 2007, the U.N. Inter-Agency Standing Committee 

(IASC) promulgated “Guidelines on Mental Health and Psychosocial Support in Emergency Settings”1

 that seek to offer a coherent, sophisticated framework for understanding and addressing 

the mental health and psychosocial needs of populations affected by conflict. 

Leonard Rubenstein

E-mail: lrubenst@jhsph.edu

Phone: 443.287.8749

Anjalee Kohli

E-mail: akohli@jhsph.edu

peaceBrieF57
© USIP 2010 • All rights reserved.

Mental Health Services During and After Armed Conflict: 

The State of Knowledge and Practice page 2 • PB 57 • September 28, 2010

On May 25, 2010, USIP’s Peacebuilding and Health Working Group met to discuss the psychosocial and mental health impacts of armed conflict, programmatic responses to mental health 

needs of populations, and how research and global guidelines can lead to better understanding 

and more effective services to address these needs. Michael Wessells, professor at the Columbia 

University Mailman School of Public Health and former co-chair of the IASC Task Force on Mental 

Health and Psychosocial Support in Emergency Settings; Judith Bass, assistant professor in the 

Department of Mental Health at the Johns Hopkins Bloomberg School of Public Health; and Eric 

Rosenthal, executive director of Disability Rights International, presented findings from their work. 

Leonard Rubenstein, coordinator of USIP Peacebuilding and Health Working Group, moderated 

the discussion.

Vulnerable Populations and Challenges in Meeting 

Their Needs

A growing body of research has established that people who witness or experience violence, 

are forced to flee their homes, or suffer deprivation of the necessities of life or disruption of their 

social networks and communities often experience severe psychological injury or distress. Studies 

consistently find that populations exposed to war experience high levels of post-traumatic stress 

disorder, depression, and other conditions, as well as loss of community cohesion. The mental 

health and psychosocial consequences of conflict can be felt broadly in populations and more 

deeply affect children, people who have pre-existing mental health conditions, and individuals 

who have been subjected to gender-based violence, forcible recruitment into armed groups, 

discrimination, or social isolation.2 In the post-conflict period, fear of sexual violence, joblessness, 

ongoing displacement and other factors may exacerbate or bring new sources of distress. The 

psychological responses of individuals exposed to the stresses stemming from war and disruption 

of social networks vary considerably. Many people living in a conflict setting show remarkable 

coping skills and resiliency and do not require specific psychosocial interventions. 

In the past, the mental health needs of people caught in armed conflict were largely ignored by 

donors, governments and providers. In recent years, mental health and psychosocial interventions 

in conflict areas have proliferated. Sophisticated and successful programs offer interventions 

and programs of services responsive to the often widely varying needs of the population, ranging from clinical treatment programs for severely affected people to holistic, community-based 

supports for larger populations are coping reasonably well but still experience distress. The overall 

record of mental health programs in emergencies, however, is quite mixed. It is not atypical for 

providers to offer a narrow set of interventions based on their prior experience or skill set rather 

than grounded in an assessment of population needs or proven effectiveness. For example, in 

some emergencies providers offer an abundance of community-based psychosocial support 

programs but no response to the needs of people who suffer the most serious mental distress or 

impaired functioning and need specialized support. Conversely, in some settings, attention has 

focused nearly exclusively on clinical support for severely affected people, with little attention to 

community-based supports. 

The field is also characterized by clinical challenges and a small evidence base. For example, some 

experts urge that the greatest attention be focused on exposure to trauma, while others believe a 

more effective response would consider underlying symptoms of anxiety or depression. Complex 

questions also arise about establishing priorities in targeting individuals for services, engaging 

persons with little formal training in mental health programming as local service providers, identifying community structures to support mental health and engaging these structures in programming. 
© USIP 2010 • All rights reserved.

Mental Health Services During and After Armed Conflict: 

The State of Knowledge and Practice page 3 • PB 57 • September 28, 2010

Comparative effectiveness research on mental health interventions in conflict and post-conflict 

settings is limited, a product both of the methodological challenges in studying these interventions and a lack of priority for health services research spending in conflict regions. Nevertheless, 

with a commitment to evaluation, appropriate studies can be designed. Given the low-resource 

context in which most of this work is done, studies are also needed to investigate the impact of 

non-mental health programs, such as economic interventions on mental health and well-being. 

These types of interventions do not reduce the need for attention to the mental health impacts of 

trauma, but can contribute to the resolution of mental health issues.3 More systematic methods of 

identifying at risk and in-need populations can also support effective interventions. 

Another concern is that mental health programs sometimes have goals beyond the immediate 

mental health needs of populations, such as reconciliation among ethnic groups or nationalities. 

Such programs may assume congruence between these political goals and individual and community needs where none exists. 

Yet another challenge is service design and human rights protection for people with more 

severe disabilities. All too often in the past, international assistance in mental health has resulted 

in replicating outmoded and abusive mental health systems or rebuilding existing institutions 

and leaving countries with segregated services systems. Even where donors and providers have 

claimed to include the needs of people with serious mental illness in post-conflict health programming, as in Kosovo, administrators responsible for health programs ignored severe abuses 

perpetrated against residents in the institutions they supported and failed to provide appropriate 

non-institutional treatment until the practices were publicly exposed. 

Consultation and participation by local stakeholders—including individuals with disabilities—is essential in addressing these challenges and providing solutions to mental health 

problems. Peer support and advocacy by people with mental disabilities can be an extremely 

important part of post-conflict recovery, particularly where there is a shortage of mental health 

professionals. Stigma and de facto or de jure discrimination against people with disabilities in 

recipient countries, however, often hinder participation by people with disabilities in assistance 

efforts and can undermine psychiatric recovery. The participation of people with mental 

disabilities can help shatter prejudices, overcome discrimination, and establish a basis for future 

participation in society, all of which represent critical components to post-crisis psychiatric 

recovery and mental health. 

The IASC Guidelines

In 2007, the Inter-Agency Standing Committee (IASC), the mechanism that brings U.N. agencies, 

NGOs and other providers together to coordinate humanitarian assistance, adopted the “Guidelines on Mental Health and Psychosocial Support in Emergency Settings”that seek to bring more 

coherence and structure to programmatic responses to mental health needs in conflict-affected 

populations.4 The guidelines are based on principles of human rights and equity and the ethical 

principle of doing no harm. They also emphasize the need to understand the local context and 

nature of the crisis in order to identify populations most in need of services. Instead of viewing 

populations affected by war as a homogenous group, all of whom equally experience psychosocial 

consequences of war, the “Guidelines on Mental Health and Psychosocial Support in Emergency 

Settings” recognize that programs need to be systematic in identifying particular vulnerable and 

affected populations as well as meeting needs shared by the entire community. The guidelines 

focus on building on available knowledge, resources and capacities in an integrated, multilayered 

support system. 
© USIP 2010 • All rights reserved.

Mental Health Services During and After Armed Conflict: 

The State of Knowledge and Practice page 4 • PB 57 • September 28, 2010

The guidelines provide that services should be modeled on a four-tiered model of increasingly 

specialized services, starting with basic services and security for all, moving next to community 

and family supports, then to focused non-specialized services, and finally to specialized services. 

They recognize the need for social interventions as well as the need to meet specialized needs of 

particular groups or individuals for clinical services. They are also designed for implementation 

that respects context and engages multiple agencies. 

The IASC guidelines are principally addressed to emergency interventions but the approach 

they take is highly relevant to long-term planning for post-conflict services. For example, integration and coordination among donors and implementers, and ending the practice of funders 

supporting a single intervention, can increase opportunities for learning across intervention areas. 

Moreover, an integrated approach can help transfer knowledge within the development and 

humanitarian community. Such an approach would avoid the kind of stovepiping that resulted in 

a lack of application of the lessons learned from psychosocial support in HIV programs to agencies 

working in armed conflict.

Finally, the guidelines confirm that mental health needs cannot be seen in isolation. Primary 

health care workers need to understand mental health and provide simple interventions as well 

as take into account survivors’ needs for privacy and adequate space for religious and other 

cultural practices. Projects emphasizing healing of individuals must recognize the need to provide 

protection of populations and prevention of violence or instability. Without safety and prevention, 

communities cannot progress in healing. 

The guidelines, however, provide a framework, not all the answers. For example, how and 

whether programs can contribute toward reconciliation, reintegration and healing remains uncertain, even though these goals remain a broad aim of programs in conflict settings. Moreover, the 

guidelines cannot successfully be implemented without the support of a growing knowledge base. 

Conclusion and recommendations

In the past, mental health services in crises were largely ignored. The availability of funding and 

programming for mental health services in recent years, though encouraging, too often is premised on the idea that doing something is better than doing nothing. Inappropriate approaches, 

however, cause harm and waste resources. Donors, providers, researchers and ministries must be 

more sophisticated in differentiating among the varying needs of subgroups within an affected 

population, designing responses for all, expanding the evidence base, and assuring that interventions do not themselves violate human rights. The IASC guidelines provide a useful starting point 

in designing programs that respect culture and human rights and respond to individual and community needs. They limit harmful practices and encouraging holistic, coordinated, comprehensive 

and community-based psychosocial approaches that are responsive to varying individual and 

population mental health needs. This requires collaboration across agencies, sectors and donors.

It is imperative to continue to share experience and build the evidence base not only as 

independent research protocols, but also as a core element of programs. Through such services 

research, the field can better understand how, whether, and for whom particular approaches are 

effective in a particular setting.

Finally, because stigma and discrimination may well be exacerbated as a result of armed conflict 

and pressures on communities, human rights protection remains essential. Such protections include assuring that people disabilities have the opportunity to participate in the design of services. 
© USIP 2010 • All rights reserved.

USIP provides the analysis, training and 

tools that prevent and end conflicts, 

promotes stability and professionalizes 

the field of peacebuilding.

For media inquiries, contact the office 

of Public Affairs and Communications, 

202.429.4725

About This Brief

The need for mental health 

services as part of emergency and 

long-term health development 

responses in regions of armed 

conflict is widely recognized. 

To date, responses have too 

often been fragmented, lack 

comprehensiveness, and based on 

assumptions rather than on evidence of effectiveness. This Peace 

Brief reviews the challenges and 

how Inter-Agency Standing Committee guidelines can point a way 

forward. Leonard Rubenstein is a 

visiting scholar at the Center for 

Public Health and Human Rights 

at the Johns Hopkins Bloomberg 

School of Public Health and is the 

coordinator of USIP’s Peacebuilding and Health Working Group. 

Anjalee Kohli is a doctoral student 

in International Health at the 

Johns Hopkins Bloomberg School 

of Public Health.

Endnotes

1. Inter-Agency Standing Committee (IASC). “IASC Guidelines on Mental Health and Psychosocial 

Support in Emergency Settings.” IASC.

2. F. Baingana, I. Bannon, and R. Thomas . “Health Nutrition and Population Discussion Paper: 

Mental Health and Conflicts: Conceptual Framework and Approaches.” World Bank. 

3. K.E. Miller and A. Rasmussen. “War exposure, daily stressors, and mental health in conflict and 

post-conflict settings: Bridging the divide between trauma-focused and psychosocial frameworks.” 

Social Science and Medicine 70, 7-16.

4. Mental Disability Rights International. “Not on the Agenda: Human Rights of People with 

Mental Disabilities in Kosovo.” Mental Disability Right International.

Mental Health Services During and After Armed Conflict: 

The State of Knowledge and Practice page 5 • PB 57 • September 28, 2010