Beyond the pyramid
Supporting the mental health of young people in humanitarian settings
In humanitarian settings, strategies for supporting the mental health of young people frequently refer to United Nations’ guidelines on mental health and psychosocial support (MHPSS)1 and social and emotional learning (SEL).2 These guidelines centre on a core ‘pyramid’ of responses that begin with family and community-based support, progressing as needed to focused psychosocial support and specialised mental health services.
Treatment for mental health impairments
Prevention of further psychological distress, and mental health conditions
Promotion of positive psychological
and emotional learning
Foundation for psychological wellbeing and
and emotional learning
Evaluation evidence from the education sector indicates that, when SEL initiatives are combined with MHPSS services for young people, they can contribute to improvements in key indicators, such as self-efficacy, self-esteem, self-agency, improved relationships, and leadership and civic action.4
Yet expert key informants also report that, in humanitarian settings, the success of the ‘pyramid’ model often depends on the availability of qualified practitioners who can provide focused psychosocial support and/or specialist mental health referral services. These services can be lacking, unaffordable, inaccessible or of poor quality. There is also concern that the pyramid model is based on a medicalised view of mental health that is not always meaningful in non-Western settings.
We recently conducted a series of case studies for the UN’s Global Child Protection Area of Responsibility. These case studies investigated mental health coping strategies and services for young people in five humanitarian settings of Bangladesh, South Sudan, Democratic Republic of Congo (DRC), Iraq (Kurdistan) and Colombia. Findings from the case studies confirmed that, while there are some examples of good practice, there are also a number of common constraints.
Across the board, we found there is a shortage of qualified or accessible mental health care practitioners, and mental healthcare for young people is fragmented and inconsistent. In these settings, there is generally a lack of youth-focused MHPSS training, guidance and standard operating procedures at the primary healthcare level. We found that, too, that mental illness is often stigmatised and understood within alternative cultural frameworks – referencing, for example, ‘heart pain’, spirit possession, witchcraft or curses. Consequently, young people and their families may cope with mental illness using a combination of ‘health seeking strategies’. Cultural rituals, herbal remedies and visits to traditional, religious or spiritual healers are often be combined with medical consultations; meanwhile, families tap into wide social networks of care and support – formal and informal – across multiple sectors.
Findings from this study have resulted in some practical recommendations for practitioners and child protection actors in humanitarian settings. These include the need to:
• Tailor mental health support for young people to context, resources and the services available. This requires an understanding of the cultural context, the stakeholder landscape, barriers to service uptake, as well as local terminology and issues of stigma.
• Engage the education system – whilst recognising the opportunities and constraints of the sector. Consider that, while teachers can play an important role in identifying problems and supporting young people in school, they may also need assistance from other role-players, such as appropriatelytrained social workers, primary healthcare workers, family welfare and child protection actors.
• Adopt a youth-focused, case management approach – we found this is most effective when a primary role-player is identified to coordinate care based on a needs-based approach across sectors. There is often scope for better engagement of traditional and faith-based sectors. Importantly, case managers must apply child protection principles and ensure voice is given to the views of young people themselves.
• Apply a socio-ecological lens5 – this could mean broadening programme engagement to the wider policy, regulatory and resource environment. It might also require evidencebased advocacy to improve the quality and accessibility of MHPSS services, so they are better tailored to the lived experience of young people in humanitarian settings.
References
1 Inter-Agency Standing Committee. (2007). Guidelines on Mental Health and Psychosocial Support. Available at: https://interagencystandingcommittee.org/
2 Inter-Agency Network for Education in Emergencies. (2016). Background Paper on Psychosocial Support and Social and Emotional Learning for Children and Youth in Emergency Settings. Available at: https:// inee.org/sites/default/files/resources/INEE_PSS-SEL_Background_Paper_ENG_v5.3.pdf
3 Adapted from the United Nations’ Inter-Agency guidelines cited above.
4 Girls’ Education Challenge. (2023). More than grades: The importance of social and emotional learning in girls’ education. Available at: More than grades: The importance of social and emotional learning in girls’ education
5 See for example, UNICEF’s Operational guidelines on community-based mental health and psychosocial support in humanitarian settings: three-tiered support for children and families 2018, p.20.