Orienting psychiatrists to working in emergencies: a WPA-WHO workshop
Authors: MARK VAN OMMEREN, LYNNE JONES, JESSICA MEARS
Journal: World Psychiatry (2010)

The Inter-Agency Standing Committee (IASC) Guidelines on Mental Health and Psychosocial Support, endorsed by heads of leading United Nations (UN) and non-UN international humanitarian agencies, provide a framework for setting up mental health services and psychosocial supports in emergencies in low and middle income countries (LAMIC) 1. Key decision-makers, such as UN resident representatives and humanitarian representatives 2, humanitarian health actors 3, numerous humanitarian agencies and leading donors, use the IASC Guidelines as their reference for what is good humanitarian response. Therefore, it is crucial that psychiatrists know the IASC Guidelines. The WPA and the World Health Organization (WHO) collaborate on mental health care in emergencies, as described in the WHO-WPA Work Plan 2008–2011 4,5,6. In 2009, as part of a joint initiative to increase psychiatrists’ capacity in humanitarian work worldwide, and with the hope that the IASC Guidelines will be used widely and appropriately with full involvement of psychiatrists in LAMIC, the WPA and the WHO organized an orientation workshop for psychiatrists. The IASC Guidelines were developed following a lack of consensus among humanitarian agencies on what should be done in response to large emergencies 7 and the consequent lack of coordination. The Guidelines focus on immediate and minimum response in emergencies with practical, intersectoral actions. The Guidelines, consistent with WHO 8 and Sphere Project 9, focus on strengthening social supports and a safe, supportive recovery environment, and also cover care for pre-existing or emergency-induced severe mental disorders, acute trauma-induced distress, and harm related to alcohol or other substance use. One of the main features of the IASC Guidelines is the focus on multisectoral action, and in particular, the coordination and collaboration between protection/social/community work and clinical services. Psychiatrists often need to adapt their role to the emergency setting. In order for their expertise to be used in the most effective way, they often need to shift from a focus on direct clinical care towards rapid training and supervision of basic mental health care integrated in nonspecialized health care in order to reach large numbers of people 10. Psychiatrists are in the best position to act as advocates for care for those with moderate and severe mental disorders. Yet, they — as specialists in mental health — are also in an excellent position to argue for a safe and supportive recovery environment and for social supports that prevent or reduce mental health problems. Thus, part of their role in emergencies is to initiate or support advocacy efforts for both clinical care and for protection/social/community work. The WPA and the WHO have recognized the need to familiarize psychiatrists to their enhanced role in emergencies, and implemented an intense five-day workshop at WHO headquarters in Geneva. The 18 participants came from 15 LAMIC, bringing with them experience and knowledge from all around the world. The workshop aimed to cover those core elements of the IASC Guidelines relevant to psychiatrists. With the help of facilitators of UN agencies (WHO, United Nations Population Fund) and leading humanitarian non-governmental organizations (International Medical Corps, Terre des Hommes, Doctors of the World-Spain/Médicos del Mundo and Doctors Without Borders/Médecins Sans Frontières), it provided a forum for exploration and discussion of the guidelines and their principles. The following topics were covered: coordination; assessment, monitoring and evaluation; grief, loss and fear; psychological first aid; setting up mental health care in primary health care; essential medicines and the inter-agency emergency health kit; mental health in health information systems; mobilizing social support through general health service; communal, family and individual treatment approaches; community mobilization; community self-help and social support; early childhood development of children in emergencies; sexual violence in emergencies; preventing harm from alcohol and substance use; epilepsy in emergencies; working with traditional healers; early recovery and reconstruction; staff care; and case studies on Darfur, Lebanon, Sierra Leone and Sri Lanka. A range of teaching methods were used throughout the course, with participatory methods for about half of the sessions. A case study was provided by one of the workshop participants, who worked at the time of the workshop in an acute humanitarian situation in what was then the world's largest closed internally displaced persons camp (275,000 people) in Vavuniya, Sri Lanka. The participant provided colleagues with a detailed overview of the resources and the numerous constraints. Participants were then asked how they would assess the community needs, how they would coordinate activities with other actors, what sort of mental health and psychosocial support programme they would create, who would provide the services and supports, and how the population would be reached. The small-group and plenary discussions that followed provided lessons for all. Points of interest, controversy and discussion that arose during the workshop included task shifting and essential medicines. These are still contentious issues that need to be discussed much more between psychiatrists (trained to optimize the health of the individual patient) and public mental health practitioners (trained to optimize the health of large segments of the population). They represent the difficulties encountered when psychiatrists are under pressure to quickly change role in these settings, and the challenge of working with the very limited types of medicines available in many acute emergencies. The evaluation of the workshop by the participants included a question about areas, if any, in which they were likely to change practice after the workshop. Most participants responded that they were keen to change their practice in two areas: a) promoting and organizing psychological first aid and b) linking mental health care with community social supports. This brief report described a WPA/WHO workshop to orient psychiatrists from LAMIC on the IASC Guidelines on Mental Health and Psychosocial Support. Many LAMIC psychiatrists’ knowledge of post-disaster mental health is limited to post-traumatic stress disorder, which, although a bona fide disorder, is only one of the many mental and psychosocial problems that occur in emergencies 11. This workshop is one step in strengthening the capacity of psychiatrists to apply a public health approach to the prevention and reduction of mental health problems in emergencies. We warmly thank Prof. Mario Maj, President of the WPA, for the initiative and collaboration, including WPA funding; those who attended the workshop for their active participation; the facilitators of diverse organizations who volunteered their time and the WPA Secretariat for organizing the logistic aspects. The views expressed in this report are those of the authors, and do not necessarily represent the decisions, policies, or views of the institutions which they serve.