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RESPONDING
TO THE PSYCHOSOCIAL & MENTAL HEALTH NEEDS OF SEXUAL VIOLENCE SURVIVORS IN
CONFLICT-AFFECTED SETTINGS
Executive
Summary
Sexual violence is an important documented correlate and consequence of conflict an estimated 1.5 billion people live in countries affected by conflict. Sexual violence can have multiple health and social effects on survivors, their social networks, and their communities. High rates of psychological problems have been documented in survivors of sexual violence in areas of armed conflict. Reported mental health problems include psychological distress; some survivors will experience symptoms of mood and anxiety disorders, post-traumatic stress disorder (PTSD) and alcohol use disorders, amongst others. Frequent social effects include stigma and its consequences--including discrimination, rejection by family and community, and further poverty
In view of the increasing awareness of the need for action, WHO, with UNICEF and UNFPA, on behalf of UN Action against Sexual Violence in Conflict, convened a technical meeting on responding to the psychosocial and mental health needs of conflict-related sexual violence survivors. The meeting was held in Ferney-Voltaire (France) from 28-30 November 2011. Twenty-nine people from 16 countries attended, representing a range of multilateral agencies, academic institutions, international non- governmental agencies, and independent practitioners. The meeting aimed to review existing evidence and experiences and propose preliminary policy, programme and research recommendations.
Two systematic literature reviews commissioned for the meeting show that the amount of research on the effectiveness of mental health interventions (n=5 studies) and psychosocial supports (n=5 studies) for sexual violence survivors in conflict-affected settings is limited; the reviews showed that the existing literature has many methodological weaknesses. Most outcomes-based research focuses on a narrow range of clinical consequences, mainly PTSD or depression. A large base of studies exists on mental health in general which has relevance for some survivors of sexual violence who experience mental health problems. The evidence tentatively suggests that a number of individual and group interventions if safely implemented may be successful in treating common mental disorders, particularly PTSD. In addition, the qualitative social science literature and various widely endorsed consensus documents (such as IASC, 2005; IASC, 2007; Sphere, 2011) on good humanitarian practice emphasize the value of community-based psychosocial programming and the importance of interventions promoting psychosocial well-being of the wider population, in addition to providing services for identified persons with specific problems.
Despite the weakness of the evidence base, there is growing intervention experience. Six intervention experiences were presented during the meeting, covering Afghanistan, the Democratic Republic of the Congo (DRC), Nepal, Sri Lanka, Syria, Liberia, Rwanda, Uganda, and Sierra Leone. In light of the available information on programming experiences, the meeting outlined a number of better practices:
Mental health and psychosocial support interventions are essential components of the comprehensive package of care that aim to protect or promote psychosocial well-being and/or prevent or treat mental disorders among sexual violence survivors.
Interventions should be rights-based, survivor-centered, and contextualize violence against women and girls.
There is a need for integrated and linked community-focused and person-focused interventions. Community-focused psychosocial interventions generally seek to enhance survivor well-being by improving the overall recovery environment. Person-focused interventions concentrate on the individual survivor. They include case-focused psychosocial care (such as psychological first aid and
linking survivors with other services), psychological interventions (such as group and individual talking therapies), and, where indicated, clinical interventions.
Interventions must be conducted in accordance with existing humanitarian guidance. All interventions and supports should be based on participatory principles and implemented, to the extent possible, together with communities. They should be based on assessment of capacities and needs, and build and strengthen existing resources and helpful practices.
Mental health and psychosocial support programming for survivors of conflict-related sexual violence should be integrated into general health and a range of other services. While the needs of sexual violence survivors must be addressed by programmes, specific targeting of sexual violence survivors should be avoided; doing so risks a range of further problems such as stigma, discrimination, and violence.
Mental health and psychosocial support planners should ensure that programmes do no harm. This requires alertness to possible adverse effects during programme planning, and measuring and recording unintended negative consequences through monitoring and evaluation.
Meeting participants agreed on key areas for action, categorized into community-focused and person-focused interventions, and prioritized according to commonly understood stages of humanitarian response. Participants agreed that activities can be selectively introduced in the acute emergency and strengthened as the situation stabilizes.
In terms of community-focused interventions:
Community-based psychosocial programming is an important element of the mental health and psychosocial response to sexual violence in most conflict-affected settings.
Interventions should aim to be socially inclusive and address stigma and its negative consequences; members of the stigmatized group must be involved in design, delivery, and evaluation.
Community-focused interventions in the acute emergency can include community mobilization activities and establishment of safe social spaces for women and children.
As the situation stabilizes, these interventions need to be expanded and socio-economic empowerment activities for women, such as village savings and loans associations, may be introduced.
In terms of person-focused interventions:
Psychosocial interventions in the acute emergency include incorporation of psychological first aid into a standard package of post-rape care offered by a (locally determined) first point of contact and linking survivors with economic and other social supports. Training and supervising care coordinators (also known as case managers) to link people – in a safe manner – to relevant services and community supports is important. Links to available social services, general health services and mental health services care must be facilitated.
Culturally appropriate services should be available for severe mental health problems. As the situation stabilizes, activities can be strengthened and expanded by training and supervising non-specialized health workers (including primary health care staff) to provide support for mental and substance use problems.
As the situation stabilizes, individual and group psychological interventions can be introduced. The meeting suggested that development and utilization of manualized, highly structured, brief, evidence-based, culturally validated and problem-oriented talk therapies is warranted. Current evidence suggests inclusion of cognitive behavioural therapeutic approaches, interpersonal therapy for depression, and brief intervention for hazardous or harmful alcohol use problems. Safe implementation is a major concern: programmes should be carefully designed, independently evaluated, and findings disseminated.
To aid in improved programming, participants agreed that two guidance documents should be developed based on current evidence and resources: 1) Do’s and don’ts for community based psychosocial programming for sexual violence in conflict affected settings; and 2) Adaptation of the evidence-based WHO Mental Health Gap Action Programme Intervention Guide (mhGAP, WHO, 2010) for non-specialized settings to conflict-affected settings, incorporating working with sexual violence survivors. Guidance is required to address acute stress reactions, bereavement, depression, psychosis, PTSD behavioural and developmental disorders, alcohol and drugs-related problems, and psychosomatic complaints, and should include guidance on talk therapies. Guidance should also include minimum requirements for training, supervision, skills, attitudes, and need for follow-up, as well as discuss additional safety and security concerns for intervening on psychological and social issues in remote or insecure settings.
Participants further prioritized areas for on-going research. These are given below.
Community-focused research areas include:
The outcomes of community-focused interventions such as community mobilization, socio-economic empowerment and safe spaces on the psychosocial well-being and mental health of survivors of sexual violence.
Identification of factors promoting psychosocial resilience among survivors of sexual violence.
Evidence for communal cultural, spiritual and religious healing practices and support mechanisms that promote functioning, psychosocial well-being and mental health and are consistent with international human rights standards.
Incorporation of rapid ethnographic assessment to improve culturally appropriate programming.
Person-focused research areas include:
The role of the community-based care worker and the place of supportive counseling in person-focused care.
Development and local validation of person-focused assessment tools and measures of functioning.
Better understanding of how to support children and adolescents;
Exploration of which psychological techniques are safe and work best with survivors of sexual violence in general and which specific cognitive behavioural techniques are feasible, safe and effective in this population.
Evaluation of single-session counseling (with no follow-up) as well as evaluation of different traditional and spiritual practices.
Although the evidence-base is weak, the need for action is very strong. This imperfect situation demands urgent intervention – following accepted best practice – in tandem with a scaling up of research and evaluation.