The world is currently facing the largest refugee crisis since World War II (1).
Every day, thousands of people are forced to flee their homes because of violence, war and persecution. The World Health Organisation (WHO) estimates that around 79.5 million people across the globe are currently displaced (2). With few safe and legal routes of passage, many migrants must undertake long and often perilous journeys in pursuit of safety, and this number will only increase as climate change renders more areas of our planet uninhabitable and political troubles lead to more displacement.
Distressing experiences prior to, during and after a person’s flight can prove to have long-lasting impacts on their mental health. Studies have indicated that refugees experience significantly higher rates of depression and anxiety disorders, particularly post-traumatic stress disorder (PTSD), than the general population. This is linked to pre-migration factors, such as war trauma, and post-migration factors, such as separation from family and poor or insecure housing (3), they may also experience exploitation or violence whilst in transit.
Psychiatrists, such as Dr Essam Daod, have emphasised the importance of immediate psychological intervention upon a refugee’s arrival in their host country (4). Dr. Daod and his team work on the Greek island of Lesbos, delivering first response mental health interventions to refugees as soon as they reach the Greek shoreline. In his recent TED Talk, he discusses the importance of what he calls the ‘Golden Hour’: during the first hour of arrival, Dr Daod suggests that it is essential that refugees, particularly children, receive psychological aid in order to be able to effectively reframe negative memories, experiences and trauma. He explains that without this intervention, these traumas are more likely to persist and contribute to long-lasting mental health issues, such as PTSD, and other adverse life outcomes.
Unfortunately, interventions such as this are rare. The majority of the world’s displaced people are hosted in developing countries (2), which lack the necessary resources and infrastructure needed to adequately support those taking refuge. They are, therefore, often unable to appropriately deal with the complex mental health needs these populations face. They may rely on international aid organisations and charities to provide support for vulnerable populations; however, these types of organisations tend to be underfunded and rely heavily on the work of volunteers.
In response to the limited number of mental health services available to those living in adverse conditions, including refugee camps, the WHO has developed a psychological intervention called Problem Management Plus (PM+) (5).
PM+ involves problem management counselling techniques plus selected behavioural strategies, hence its name (6). PM+ aims to help reduce the psychological burden people in adverse settings experience whilst also teaching them ways to more successfully navigate difficult social circumstances. The PM+ course tends to consist of a total of five sessions which are each 90-minutes long and run once a week. Assessment tools are completed by clients throughout the PM+ course to enable those delivering the intervention to track their progress. It was initially designed for one-to-one use but has now been successfully scaled up for group settings. Smartphone compatible formats have also scaled up the reach of this training significantly.
PM+ takes a ‘problem management’ approach as opposed to a ‘problem-solving’ one. A lot of the problems individuals partaking in PM+ experience, like displacement, violence within camps and poverty, are largely out of their control and therefore not ‘solvable’. Instead, those that deliver PM+ attempt to provide tools that enable their clients to better manage the practical, day-to-day issues they may be faced with, such as unemployment or interpersonal conflict.
In many cultures, counselling is unheard of and mental health problems are often considered a taboo. This can often make people reluctant to participate in psychological interventions. One of the huge strengths of this intervention is the dedication of its creators to making it culturally appropriate. With the help of key stakeholders, they have adapted PM+ resources to the various settings the programme is delivered in, in order to enable clients to overcome cultural barriers they may experience when accessing it. Manuals and tools have also been translated into a variety of different local languages with the inclusion of commonly used expressions and metaphors.
One of the huge benefits of PM+ is that it does not require a mental health practitioner to deliver it, instead, non-specialists with any level of education from high school upwards can undergo two weeks of intensive training to deliver the course. Some may argue that the mental health issues of these populations are too complex to allow people with such limited training to administer psychological interventions such as this. However, mental health specialists are usually limited in number in these types of settings, therefore utilising the skills of lay people is often necessary.
PM+ has a transdiagnostic approach - it is effective at tackling a range of mental health problems. Its focus is not to provide individuals with a medical diagnosis, nor does it offer targeted support for specific mental health conditions. However, trials of both the individual and group versions of PM+ have been conducted in Pakistan, Kenya and Nepal, and have all shown great success at supporting people with mood and anxiety disorders (7). A Randomised Controlled Trial performed in Nairobi, Kenya, on women survivors of adversity, including gender-based violence (GBV), who were experiencing PTSD symptoms, demonstrated a significant reduction in participants’ symptoms after they had received PM+ (8). Like any intervention though, one size does not fit all. PM+ cannot be used on clients who are actively suicidal or on those who suffer with severe mental health disorders, such as psychosis.
Other aspects of the PM+ course include stress management techniques such as breath control, meditation and exercise routines. For example, the ‘Get Going, Keep Doing’ programme emphasises that vital role that movement has to play in improving low mood. There are also resources dedicated to helping clients strengthen their social support network, teaching them how to utilise the people around them to protect their mental health.
Once further trials into its efficacy have been performed, PM+ will hopefully be more widely implemented into other adverse settings. Here at Aceso, we believe that PM+ will prove itself to be an invaluable tool not only for developing nations who are unable to provide refugee communities with psychological interventions, but industrialised countries, such as the UK, where mental health resources are becoming increasingly stretched.
Doctors of the World. World Refugee Day 2019. Doctors of the World. [External Link]. Published 2019. Accessed 26th December 2020.
UNHCR. Figures at a glance. UNHCR. [External Link] Published 2018. Accessed 2020 26th December.
Mental Health Foundation. Mental Health Statistics: Refugees and Asylum Seekers. Mental Health Foundation. [External Link] Published 2018. Accessed 26th December 2020.
Essam Daod. "How We Can Bring Mental Health Support to Refugees". TED. [External Link] Published 2018. Accessed 26th December 2020.
Sijbrandij M., Acaturk C., Bird M., Bryant R.A., Burchert S., Carswell K., et al. Strengthening Mental Health Care Systems for Syrian Refugees in Europe and the Middle East: integrating scalable psychological interventions in eight countries. European Journal of Psychotraumatology. 2017;8(sup2):1388102. [External Link] Accessed 26th December 2020.
World Health Organisation. Problem Management plus (PM+): Individual Psychological Help for Adults Impaired by Distress in Communities Exposed to Adversity. World Health Organisation. World Health Organisation. [External Link] Published 2016. Accessed 26th December 2020.
Mental Health Innovation Network. Problem Management Plus (PM+) [Internet]. Mental Health Innovation Network. [External Link] Published 2015. Accessed 26th December 2020.
Dawson K.S., Schafer A., Anjuri D., Ndogoni L., Musyoki C., Sijbrnadij M., et al. Feasibility trial of a scalable psychological intervention for women affected by urban adversity and gender-based violence in Nairobi. BMC Psychiatry. 2016;16(1). [External Link] Accessed 26th December 2020.