Interview with Dr. Mike Wessells

Biography:

Dr. Michael Wessells is a Professor at Columbia University in the program on Forced Migration and Health. A long time psychosocial and child protection practitioner, he is former Co-Chair of the IASC Task Force on Mental Health and Psychosocial Support in Emergency Settings. Formerly, he served as co-focal point on mental health and psychosocial support for the revision of the Sphere humanitarian standards. He has conducted extensive research on the holistic impacts of war and political violence on children, and he is author of Child soldiers: From violence to protection (Harvard University Press, 2006). Currently, he is lead researcher on inter-agency, multi-country action research on strengthening community-based child protection mechanisms by enabling effective linkages with national child protection systems. He regularly advises UN agencies, governments, and donors on issues of child protection and psychosocial support, including in communities and schools. Throughout Africa and Asia, he helps to develop community-based, culturally grounded programs that assist people affected by armed conflict and natural disasters.

What are the most important factors that comprise effective psychosocial interventions for youth in developing countries?

A really key thing is to take an ecological, holistic, culturally grounded approach, though this is very seldom done. Let me explain a little bit about what I mean. The ecological approach assumes that psychosocial distress and mental disorders frequently stem from bad things that are happening to children in their social environments. It could be exposure to war, disaster, sexual abuse, bullying, etc. What you typically see in the psychosocial field is a focus on only one level of children's social ecologies, let's say the family level. Family level psychosocial support is really crucial, but it's definitely not enough. A child might be well supported in the family yet may get bullied or sexually abused at school, and this undermines their well-being. The key to an ecological approach is to think about providing supports at multiple levels of children's social ecologies: the family, the peer group in the neighborhood, the school, the wider community, and the society. The key is to coordinate and to enable rich interconnections between psychosocial supports operating at these different levels.  The same point regarding risks applies also to the need for ecologically developed supports for children. What happens if schools are encourage children to open up and to talk freely about feelings, but at home they get punished for talking about their feelings or start feeling criticized? This is a real problem.

Also, it is terribly important to not treat young people as if they are all the same.

Gender, ethnicity, religion, sexual orientation, and ability status all make a huge difference.

An effective psychosocial intervention needs to be tailored to fit the people whom you’re working with.

What works for boys may not be so good for girls, and what works for Buddhists may not be so good for Muslims. An intervention that works well for many children may not be appropriate or accessible for children with disabilities.

It is really crucial to follow the IASC guidelines on mental health and psychosocial support in emergency settings by developing multiple layers of psychosocial support, as we can picture in terms of an intervention pyramid. The base of the pyramid, which supports the largest number of children, deals with providing safety, security and meeting basic needs in a way that supports people's dignity and well-being. This layer invites us to think how to integrate psychosocial support into multiple sectors of humanitarian aid. For example, if there are young mothers who need food in the midst of an emergency but have to stand with their babies under an incredibly hot sun in line for hours, that’s not a psychosocially supportive approach. Coming up to the next layer, people may be separated from their families, or there may be community disruption, including disruption of education. So that second layer is family and community support, which includes processes such as family reunification and provision of education for children, both of which can have significant psychosocial benefits. Coming up to the third layer, there's often a need for focused individual supports that are not therapeutic and are not done by a professional psychologist. For example, in many war zones, women who feel isolated by virtue of stigma may be need individual supports to help access basic services, re-enter social networks, or even meet their personal health or economic needs. At the top of the pyramid is the smallest number of people, but an important group nonetheless. These are the people who have been so profoundly affected that they are emotionally overwhelmed or in need of specialized psychiatric or clinical psychological support. This is the layer in which we think about therapy, which is often unavailable in war zones on the scale that is needed. In considering war-affected children or all emergency-affected children, we think about children and youth as fitting in these different levels, and they may have multiple needs at multiple levels. A girl who has been separated from her family may also be in need of specialized therapeutic support. It’s important to provide all of these layers- and that's really hard to do because it requires coordination across agencies which, in every emergency, is one of the hardest things to achieve.

Psychosocial support programs sometimes start with international guidelines and with agencies’ preconceptions, when they should begin with listening. If I'm working for an NGO that helps people at the top of the pyramid, I may be thinking PTSD, depression, anxiety and so on. These problems are very real and necessitate therapeutic supports for the people who need them. But it's not a good thing if I go out and look only for those without considering the views of the affected people themselves.

The key is to start with listening to and learning from young people-- to girls and boys who are situated differently.

They may tell you that their biggest problem is that they feel threatened or under attack by angry spirits. Such spiritualistic, indigenous views don’t usually fit international guidelines or conform to what western psychiatrists typically talk about. What are you supposed to do with that? My answer to that is, you listen respectfully, and you learn, and you don't throw it out the window as something that seems to be superstitious or not congruent with international guidelines. It’s appropriate to view it potentially as a culturally constructed idiom of mental health and psychosocial well-being, and to try to learn about it.

In addition to listening, flexibility and support for children’s agency are key. When you look at international guidelines, sometimes it seems as if they are creating a recipe. But the best psychosocial interventions do not follow a recipe; they start with listening and learning, and they try to fit the local context. To learn about the local context, we should build into our situation analysis listening to and learning from not only adults but also teenage girls and boys, young children, and school age children. We should be learning about cultural beliefs and practices, protective factors as well as risk factors, and how to enable young people’s agency without undermining their relationships with adults. The evidence is quite clear that when young people or adults for that matter, experience a sense of helplessness and victimhood being recipients of charity-- that actually does not help people's mental health and psychosocial well-being. If children have a sense of self-efficacy and of agency, this contributes to their psychosocial wellbeing. For these reasons, we should start by listening and learning, understanding the context and the culture, and recruit people’s own ideas about what would help them the most, rather than coming in with pre-packaged psychosocial inventions.

How might these factors be applied to education in emergency responses during the COVID-19 crisis?

During the COVID-19 crisis, people are spending more time with their families.

In many of the countries that I’ve worked in, in sub-Saharan Africa, Asia, and other places, young women who spend more time at home are more likely to experience intimate partner violence and sexual abuse. It is profoundly important to think about this and to try to develop protection against violence at home before or alongside efforts to develop psychosocial support interventions.

It's really crucial to link protection with psychosocial support, as protection is an important piece of the prevention arm of psychosocial well-being.

Education during the pandemic could, if done well, help to strengthen protection and would also help to strengthen the hope of young people. During the pandemic, people are increasingly isolated from their peer group, which is one of the most important protective factors or risk factors. As the pandemic situation allows local, it can be very useful to create safe environments where learning in small groups occurs, even amidst the pandemic. At the community level, it's quite difficult to have large community meetings, if people are trying to achieve social distancing and adhere to public health protocols. In Kenya, the police have actually ruled out community meetings and you're actually liable to get shot if you come out of strict containment and even show yourself in public. This is a big psychosocial issue, as it creates powerful fear and resentment toward the government.

On top of these challenges to people’s psychosocial well-being come severe economic challenges, which themselves create tremendous suffering and stress.

A significant question is whether Western public health methods of dealing with COVID are appropriate in areas that are extremely poor, where you can't afford to slow down the economy or you’ll cause more deaths.

For example, in the urban slums of Freetown, Sierra Leone, it would be very difficult to slow down the economic activity, because people are living right on the edge of starvation. What’s being done there is people are being encouraged to wear masks which I support, and to engage in social distancing to the extent that they can. It’s a bit challenging, but it's just to say that we need a very contextual approach, to both psychosocial support and on the public health side.

With regard to the psychosocial support, culture is a really key thing to keep in mind. In Sierra Leone, during the Ebola crisis, one of the worst parts was people were ordered not to do their culturally appropriate burial traditions, which, in the Islamic tradition involved touching the bodies and, of course, if you did that, when bodies were hot with infection, even after death, you would get a horrendous spread of the disease.

I'm hoping that we're going to learn a little bit from that and try to learn how people are understanding COVID, and what are some of the culturally appropriate responses. One of the things that is being done with the teams that I work with, including through UNICEF Sierra Leone, is we’ve invited communities themselves to think of how they can help prevent the spread of infection, so in other words, it's not all dictated by us, the outsiders; it's being done by the local chieftains and by local groups.

Even though Western public health approaches need to be drastically altered to be applied in areas such as Sierra Leone, are there any components of Western approaches that can be generally applied to different cultural settings?

I think wearing masks and social distancing--the basic elements that are recommended by the WHO and CDC--are universal and well-indicated. Frequent hand-washing is universally important, though it’s not highly achievable in places where there is no clean water or access to soap. What's less universal is the idea of large-scale containment and shutting the economy down. I'm totally in favor of that when it's needed, for example, in New York City. Why? Because we have a strong economy, we can bounce back from that. But when people are living on the edge of starvation, a couple of weeks without economic activity could produce a much higher death rate than might occur had people been allowed to conduct at least some form of minimal economic activities. Public health workers are realizing that you may have to take different approaches in different placements with regard to enabling economic activities to continue.

On the psychosocial side, I would say that we have to listen and learn once again. We know that universally, intimate partner violence and sexual violence are problems. In Sierra Leone, one of the key things that we learned during the Ebola crisis was that poverty was worsened. When poverty is worsened, one of the first things that happens for teenage girls is they feel a need to go out and help their families by performing survival sex as a means of earning income to get food to help their families. It's not an issue of immorality or bad behavior but of survival of your family. Unfortunately, men who may have more money and resources, understand this and they're willing to exploit the teenage girls in such a horrible way.

In the long run, we need to change the gender norms, the idea that girls and women are sex objects and can be manipulated according to who has the power and the money. In the short term, it means that we have to find ways of helping families to meet their basic needs without the sexual exploitation of girls and women. This is a very difficult thing to do in the midst of an emergency, but I would put it near top of my list.

The other thing that happens is that, because families starving, girls drop out of education. In Sierra Leone and lots of the other countries I work in, youth will be very quick to tell you that they see education, even during an emergency, as being fundamental for their well-being, and most young people view school as their future. To be deprived of education just because there's an emergency is a nonstarter. I say “just because there's an emergency” not to make light of the pandemic, but to remind us that we may be experiencing our first emergency, but if you live in places like Sierra Leone or South Sudan or Syria, it’s not the first time. These emergencies are woven into the fabric of everyday life. We have to find ways of helping people protect their right to education, but also protect them from scourges like sexual violence. There are ways of doing this, but it requires systematic thinking, prioritization of prevention of sexual violence and exploitation, and careful thinking about how to enable food security for families.

A major impediment to such a systemic approach is that the humanitarian enterprise is divided into silos. The problem with that is that human functioning does not conform to silos but his holistic. It’s useful for psychologists to want to provide mental health and psychosocial supports for girls who have been sexually exploited. Yet this approach does not get very far if there is little attention to prevention. As said earlier, doing prevention often requires attention to girls’ and families’ economic circumstances. It is quite rare, however, to find psychologists and economists collaborating in the development of more systemic, holistic approaches. We need to break down these barriers between the silos and think a little more holistically.

Education is very important and psychosocial interventions are very effective when implemented in schools. Since not every child will have access to education in general or in emergencies, how can psychosocial interventions be implemented in the absence of a structured educational system?

Useful possibilities could be to develop psychosocial interventions and supports at different ecological levels but outside of formal schools. Families are key sources of potential psychosocial support, as are communities. So, it would make sense to develop supports—especially the non-therapeutic supports-- at family and community level. Supports at community level can reach and help significant numbers of children. It’s at the community level that we find natural helpers such as religious leaders, grannies, youth group leaders, etc.—who are very skilled at supporting vulnerable children. Often, valuable supports can be developed or delivered by existing groups such as women’s groups, youth groups, or religious groups. One should never underestimate the importance of peer supports, even if they need to be complemented with more specialized supports.

A highly valuable resource is a peer group that recognizes when people are struggling with mental health and psychosocial issue and that reaches out to these individuals, provides support, and if needed, encourages them to talk with specialized care providers. Community level supports are also key because they frequently include cultural resources that Western trained psychologists and psychiatrists may not think of. For example, performing burial rituals for loved ones who have died can be highly important for children. Having culturally relevant supports is hugely important for their success. In many humanitarian settings, specialists and agencies often think more about standardized interventions than about approaches that are most meaningful and impactful for the affected people. This is another reason why we should start by listening and learning.

How can public policy responses better support psychosocial interventions, or education in emergencies, especially during the COVID-19 crisis?

Public policy leaders need to prioritize MHPSS and to do it in a way that is holistic that does not ring the bells with regard to stigma. In some countries if you even use the phrase “mental health and psychosocial support,” it means “you are crazy”, which is highly stigmatizing. At the grassroots level, we need to find a way to talk about the well-being of youth and to talk about it in a holistic way, without even using the terms “mental health” and “psychosocial support.” We also need to think about different ecological levels and move away from medicalized, individualized intervention. This requires attention to what goes on in the family and at the intimate partner level, and it requires thinking about the importance of building psychosocial support into education and non-formal learning. Enabling peer-based support is really a valuable thing to do. I think that policymakers, unfortunately, sometimes think only about trauma and specialized intervention. A majority of people affected by the pandemic or any other emergency for that matter are not going to need medicalized kinds of support. Here, I think we need to remember that relationships matter.

With respect to education, we should help policy makers appreciate that access to and participation in education is a fundamental right of all children and that children themselves see education as one of their highest priorities. We should also help policy makers to understand that education is protective, strengthens children’s resilience, and enables the rising generation to become effective, productive citizens.

A dilemma in the era of the COVID-19 pandemic is how to provide access to quality education.

If large numbers of children go to relatively crowded schools, the suffering and deaths from the pandemic will likely increase. If we adapt by providing education via the internet, we run into significant problems of discrimination since in many LAMIC countries, children lack access to the internet or to sufficient quality internet, and do not own computers. One thing that I would consider because I've seen this done in Afghanistan, even during the rule of the Taliban, was to organize education, informally, in small groups of fewer than ten children. It could be done in a way where people wear masks and interact with one another. That, for me, is potentially more promising than assuming that everyone's going to be able to access education electronically.

We need work according to context and by all means make sure that inclusivity is a top priority. I would argue that we ought to do this very quickly. Keeping children away from education is really damaging, and I believe that in the current environment, it is possible. It's just that we have to be a bit more flexible and creative than usual, and a little nimbler.

In working with policy makers, we should emphasize the importance of supporting teachers, who themselves are frequently overwhelmed by the emergency and unsure how to support children who have been affected. Without helping the teachers to come to terms with what they have been through and to cope with their current stresses, they will not be in a good position to help crisis-affected children. We should also emphasize to policy maker the importance of teachers creating a safe, supportive environment. In countries such as Ukraine, this has required changing the orientation of teachers from being emotionally remote authority figures—a holdover of the old Soviet model—to being emotionally supportive and accessible helpers who enable children to cope with their stresses. UNICEF/Ukraine has been very involved in this approach and has also had some success in enabling effective mechanisms for the referral and treatment of children who need specialized care.

Lastly, help policy makers to remember the importance of the economic aspects of sending children to school. If young people are going to be at greater risk because their families are hungry or they're hungry, or they can't go to school because they have to work to help their families survive, we're not going to provide good psychosocial support unless we also attend to relieving the profound economic stresses that face young people and their families during the COVID crisis. This brings us full circle, back to the importance of a holistic approach in supporting the protection, education, and well-being of children.