“Psychological intervention for populations under ongoing threat” presented at the IFRC Research Carnival

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The paper is a summary of my presentation and panel discussion at the IFRC Psychosocial Centre Research Carnival that took place in Copenhagen on September 11-13, 2023. The conference was hosted by the Red Cross Red Crescent Research Network, a network that brings together academic researchers and mental health and psychosocial support (MHPSS) practitioners to provide effective humanitarian action through understanding and advancing evidence-based practice. The Carnival was titled Learning from MHPSS in Climate Change, Conflict and Migration.

The conference presentation was based on my published systematic review on the effectiveness and feasibility of psychological interventions for populations under ongoing threat. The current article aims to provide an overview of the presentation, document the subsequent discussion with conference delegates, and synthesise practice implications for MHPSS researchers and practitioners. Whilst presenting the findings of the published systematic review is not aimed for here, a summary of the findings is described hereunder. For more details of the contents of the systematic review, please refer to Yim et al. (2024).

The topic of ongoing threat is pertinent given the increasing number of conflicts around the globe. In particular, the review focuses on two types of ongoing threats: ongoing political/ armed/ community violence and ongoing intimate partner violence (IPV). This begs the question of the validity of psychological treatments for psychological trauma, given many of them have been developed based on the concept of posttraumatic stress. The review examines the effectiveness and feasibility of such psychological interventions in the context of ongoing threat, where feasibility involves both the unstable as well as cultural contexts. The reviewed interventions are those at the top two levels of the Inter-Agency Standing Committee (IASC) pyramid (i.e., specialised interventions;IASC, 2007).

A total of 15 unique studies are included in the review, with 12 studies focused on community/ political violence and three focused on IPV. Eleven studies involve randomised controlled trials (RCT). Most of the included interventions are variations of cognitive behavioural therapy (CBT), such as trauma-focused CBT, teaching recovery techniques (TRT), cognitive processing therapy (CPT), narrative exposure therapy (NET), and the common elements treatment approach (CETA). No evidence was found in the included studies suggesting that psychological interventions for those experiencing trauma are counter-productive. Most of the studies showed a positive effect on posttraumatic stress-related outcomes. Smaller effect or nonsignificant effects were found regarding secondary outcomes such as depression and grief. Evidence has also been for the feasibility of treatment and its application by non-specialists (i.e., task-shifting). Nevertheless, two studies were terminated prematurely due to the increasing threat to the research team and health workers involved; one study described how the research team was unable to travel to the region of study due to security concerns, while the other described how lay counsellors had dropped out due to personal trauma. Cultural adaptations have been summarised in detail in Yim et al. (2024).

Research and Practice Gap

Based on the presentations of other MHPSS practitioners, my understanding is that most work in the field has focused on psychosocial support (PSS) and present-focused support rather than specialist, past/trauma-focused mental health interventions such as CBT in settings of protracted conflicts. On the other hand, some practitioners also expressed surprise that the review did not yield many studies on eye movement and desensitisation reprocessing (EMDR) therapy, despite their personal findings on EMDR’s usefulness in practice. The keynote speaker Professor Wietse Tol described their team’s recent MHPSS research priority-setting paper. The top research priority was not on intervention effectiveness. Instead, the top research questions were on strengthening the MHPSS workforce and developing appropriate monitoring and evaluation (M&E) systems and methodologies (Tol et al., 2023). As a potentially controversial topic, some researchers and practitioners have also advocated for trauma-focused work in unstable contexts such as in refugee camps (Schauer et al., 2011), whereas others have advocated for considering daily stressors using present-focused approaches when populations are in humanitarian crises (Miller & Rasmussen., 2010). The attendees reflected upon the discrepancy between the review findings and what is happening on the ground and wondered whether future research could focus on the time specificity of people’s needs and readiness, which may help guide practitioners when the focus of MHPSS shifts from PSS to MH. The conference discussion sparked some interesting ideas for future research, including the reporting of daily functioning and quality of life outcomes in addition to the symptomatic outcomes, which would then allow a head-to-head comparison of different interventions.

The review shows the research to be of mixed quality. Conclusive evidence thus cannot be made due to methodological differences (e.g., differences in baseline group characteristics, outcome measures, conceptualisations of ongoing threat). Most research studies relied on measures on PTSD to conceptualise the interventions. To address this, MHPSS practitioners can play a key role in contributing to the understanding of the unique nature of ongoing threat in relation to people’s psychological responses to support the development of appropriate outcome indicators.

Attendees raised useful future research questions based on the review findings and their practice experiences. A delegate raised one important point of whether perceived threat rather than level of objective threat is able to moderate the intervention effectiveness. This is a worthy topic to explore in future research. Another delegate noted the need to exercise caution when engaging in task-shifting (i.e., using non-specialists to deliver care): lay members of the community also have personal trauma that may impact their engagement and ability to provide interventions. Discussions are needed centred around developing and implementing evidence-based staff supervision models for ongoing threat contexts.

Generalisability of the published review (Yim et al. 2024)

The panel discussion and audience Q&A raised questions and new avenues of approach about the definition and scope of ongoing threat. Whilst the review focused on armed conflicts and IPV, some delegates asked about climate change as another example of ongoing threat. In the same vein, due to the publication of the review, practitioners from high-income countries have approached and discussed the relevance of the review in high-income countries. For example, ongoing threat can be a potentially useful concept for understanding the plights among people of colour who experience ongoing racism or among asylum seekers who face long periods of uncertainty due to their asylum applications and unstable housing. Whilst the described populations share similarities with the populations included in the review, caution should be exercised when generalising the findings across different settings. In the review, Bonilla-Escobar et al.’s (2018) study demonstrated the importance of understanding idiosyncrasies across settings, with the studied intervention being effective in one municipality in Colombia but not in the other one. This is a developing field, and while ongoing threat does not automatically imply that interventions should be denied or deemed ineffective, the evidence is not entirely clear across all forms of ongoing threat. Treatment decisions will rely in many ways on practitioners’ expertise and individualised formulations. I hope that the review and discussion can ignite researchers’ and practitioners’ interest in exploring the applications and limitations of delivering psychological interventions in various settings. Another line of enquiry relates to the distinction of acute versus protracted ongoing threat. Areas of acute and active conflict were specified to occur outside of the scope of the review (Yim et al., 2024). In humanitarian settings, however, crises may be prolonged, and endings are not clearly defined. For example, whilst a natural disaster may be an acute crisis, climate change may mean that the natural disasters become more frequent, which would have an impact on people’s needs. Similarly, the line between ongoing, protracted conflict and acute conflict may be blurry. Protracted armed conflicts can be episodic, at a standstill, or longstanding and include forms of violence other than war, such as occupational conflicts where violence simmers and is at a lower level compared to the traditional conceptualisation of armed conflict (Policinski & Kuzmanovic, 2019). The review also found 60% of the conflicts that had ceased in early 2000s to have resurged within five years (von Einsiedel, 2017).

Overall, the attendees noted that MHPSS work does not come in isolation. Intervention effectiveness is potentially limited by other disciplines such as integration and peacebuilding in humanitarian settings. For example, whilst providing psychological support may be helpful for survivors of ongoing IPV, strengthening the work in shelters and supporting people towards independence are also important. This shows the importance of cross-disciplinary efforts within humanitarian settings. I hope that the discussion and conversations can continue within the IFRC Research Network and foster more meaningful collaborations between researchers and practitioners.

Peer-review
Not peer-reviewed

Funding
This research received no external funding.

Disclosure statement
The authors report no conflict of interest.

Author’s ORCID numbers
See Heng Yim
0000-0002-2241-1017