Mr. Saji Thomas on Mental Health and Psychosocial Support during COVID-19

Biography: Mr. Saji Thomas is the current Chief of Child Protection in UNICEF Egypt. Mr. Thomas joined UNICEF in 2005 in India. After working across India and Sri Lanka, Mr. Thomas transferred to UNICEF HQ in NYC, where he worked as a Child Protection Specialist in Mental Health and Psychosocial Support and Community-based Protection Mechanisms in Emergencies. Mr. Thomas also serves as the Co-Chair of the Inter-agency Standing Committee Reference Group on Mental Health and Psychosocial Support.

What are the most important factors that comprise effective psychosocial interventions for youth in developing countries? One factor is creating a platform that young people can relate to and can respond to their needs. One of the first psychosocial interventions I was part of was in India in 2006 when we worked with the National Network of Youth. We engaged them to respond to the tsunami crisis. So you already had a network, and we tapped into that network. I know they were all enthusiastic young people who wanted to be part of something. But then we took the psychosocial package that we had to the youth and engaged them. Basically, we were building on their resources, their capacities, and their abilities to be resilient. In that initiative, we were looking to the youth as a resource. Many of the youth were equally affected by the tsunami crisis but we didn’t go to them saying, “We are here to offer support.” Instead, we went to them saying, “We want to be part of something that UNICEF is trying to do,” and that’s how they responded. The National Network of Youth was a big network and owned by the government of India, but it was quite voluntary in nature. We ran quite a cost-effective model there because we were not spending the way that we were doing with other NGOs and international agencies. Investment was quite minimal but there was a lot of engagement by youth and interest on their part in knowing what this new field is. Our success also lies in making Mental Health and Psychosocial Support (MHPSS) for what it is – it’s not rocket science. MHPSS is basically simple methods of how we can tap into each other’s resources and be there to support each other. We tried to make it less technical and something that people can relate to. I think that’s the value that the global guidance brings at some point by making MHPSS something that people can relate to.

How might you apply psychosocial interventions to the COVID-19 crisis? I look at two things: one is the opportunity. Once you create a platform you do tend to see youth participating, especially in Egypt. We do have the social media presence in the net forms. The penetration is quite high even in different religious youngsters, and families do have smartphones (they may be not iPhones but something people can use). So, they’re all on social media. Some of the campaigns that we run, if you go online and see some of the annual reports, you will see that the reach is very high. Some of the campaigns like “Ending violence against children” last year we reached 90 million views. The engagement was 2-3 million, or 5% of views, which for social media I believe is quite a good rate of engagement. They don’t just click but they also engage. So that’s the opportunity in having a youth population. Not all of the big numbers I spoke about are youngsters, but a significant amount of them are young people. The point being, once you cleared those kinds of platforms, the reach is there and they can be engaged, so that I think is the opportunity. You have to come up with something that can reach people, then you create a platform that they can engage in.

That’s where the challenge also is because right now it’s all quite remote. You don’t go out into communities. So how do we create a platform that will not only reach young people but can also give you feedback? This is something we and some of our partners are trying right now especially with children on the move or migrating children. We use WhatsApp groups to send certain messages, and the children come back and get in touch with you by responding to those messages. A lot of the lessons from offline work we should be trying to do online. It’s not a complete solution because obviously a lot of the young people and children that we should be concerned about still don’t have access to cellphones and smartphones and technology. But at least with those who have, we can translate some of our learnings offline to online platforms. That’s what we are trying to do with at least some of our partners. So, opportunity is there but challenges of how we apply it to online platforms.

And then my last point is that if you have a youth center, you know that some of the young people who come there at least thrice a week. Then, there is a package we introduce and over the period of six months you reach “x” number of young people with the package, and they were all engaged because they were coming to these youth centers three times a week. Right now, the challenge is that access is limited so how do we make sure that the package is something they can engage with and they benefit from? You can see a message on WhatsApp and it may have no impact on people who see it. That I would say is the opportunity but also the challenge in applying what we know offline into something online during COVID-19.

To which parts of the specific culture and values of a community should a response team pay most attention to, and why? I think that has been the crux of a lot of the work we do globally. We aim to somehow demystify mental health and psychosocial support by showing that a lot of the communities have solutions within them to relate and cope. If you know that out of 100 cases only 3-5% need specialized care, 15-20% need some kind of focused support, then the vast majority of people can easily cope with community networks with others. What I hear constantly in Egypt or in India or even in Sri Lanka is that many of these communities have a social cohesion component. They’re not individualistic and it’s quite simplistic to put it that way, but I do think that there is some element of truth in that because when something goes wrong in these community settings, everybody comes around. When I was at UNICEF HQ we had a lot of people working with us on this. It’s what most of these communities do anyways. You are there to listen, and you are there to see what’s going on. You are there to mobilize resources in which they can support people.

I think the key challenge is not so much in communities because they have their own ways in coping, but the way we introduce the topic of Mental Health and Psychosocial Support. Because despite all the thinking globally and at different levels on this, very often we go with this mental health flag and that sometimes destabilizes because they think, “Oh we need psychiatrics now,” “We need psychologists now,” “We need sessions with the shrinks.” Even in Egypt, I hear a lot of that language. You do need specialized care for a small percentage, but I think the key thing is to demystify and focus a lot of community resilience by saying, “95% of the mental health is within you, with you; you have the capacities.” Only when you lose that for that for 3-5% do you reach out to specialists. Even now, despite all the good work we do, sometimes the messages that come out from top leadership are very focused on mental health without an equal emphasis also on psychosocial wellbeing and psychosocial support. Even now, some of the ED messages are around mental health and suddenly people are talking about how many people are there, how many psychiatrists are there, how many psychologists are there. Of course they are needed but they aren’t the solution. If you look at many of the developing countries, having a good number of psychologists and psychiatrists hasn’t really reduced incidences of depression. Basically, my point was that we need to package Mental Health and Psychosocial Support as a composite package and never lose focus on this whole psychosocial part of it. All the messaging around it starts with resilience and you having the capacities to deal with it. And then you draw the attention for specialized care for a small number of people. We have to constantly get that balance right. Always the top leadership is questioning things like “Mental health – what’s happening? How many psychologists/psychiatrists?” You need to ask those questions but towards the end.

Could you speak more about your work on developing the IASC guidelines for MHPSS?

IASC Guidelines: https://interagencystandingcommittee.org/iasc-reference-group-mental-health-and-psychosocial-support-emergency-settings/iasc-common

I came into IASC when the guidelines were already developed. I contributed when I was in the field and then when I moved in to IASC the guidelines were already there so my role was to undertake a review of how the guidelines were being implemented. We had all actors (e.g. WHO, etc.) and we aimed to develop a framework because MHPSS for UNICEF was one of the biggest areas of spending especially in Child Protection. We were spending over $100 million every year. It’s one of the biggest areas of spending for Child Protection but then questions arose over what impact MHPSS has and if we can even measure MHPSS at all. So, one thing we led at the agency level was to develop this framework. Those were the two things apart from a lot of other things that we did. One was to undertake a review of the implementation of the guidelines. The other was to show that there are ways we can measure mental health and psychosocial support. I think the sum of it all, the contribution of all these series of initiatives was that as the global learning shows, we should not end up clinicalizing the whole field of mental health and psychosocial support. You need specialized care and it has its own place, but the emphasis has to be on resilience and community support. I think all of these tools contribute to that in some way or another.

Would you change or adjust any of the IASC guidelines on MHPSS? I don’t think we would change a lot in terms of the way it is structured. It still has the right balance in terms of specialized care, focused support, etc. I think one thing we were discussing and we didn’t go very far with was that every time you put a structure, people get stuck with the structure. Just because you have a pyramid, people get obsessed with the pyramid wondering where does one intervention we introduce go in those layers of the pyramid. We were saying that structures are just to help you think through. An intervention that you do can be across all those layers of the pyramid so don’t get too obsessed with those layers of the pyramid in saying where your interventions fit. That I try to communicate even more convincingly. Don’t get too obsessed with the structure that is being provided. Look at the principles behind it. Look at the understanding that is conveyed through creating such a tool to help you program.

How can public policy responses better support psychosocial interventions, or education in emergencies, for youth in developing countries? A lot of the global guidance is there and there is a lot of thinking that goes into both developing and reviewing this. There is a lot of knowledge and insight that is being captured in all this, but I do wonder how many policymakers look at some of those lessons that are being drawn, especially initially MHPSS, which is crosscutting in nature, sometimes tends to get ignored and unless there is someone to really push, they will not really look at it. I think the key thing is to make sure that policymakers at different levels, irrespective of what they’re looking at but if it’s anything to do with public health, education, or gender protection, look at psychosocial as a key domain of programming or engagement and then see what the learnings are. There’s plenty there and then trying to mainstream it. I would say literally look at the framework and global guidance and there is so much being provided in terms of what we can do and what we can measure. I would say to policymakers that’s the appeal. Look at all the good lessons and insight being captured through, not a plethora of documents, but at least a review of the guidelines and framework. Even if you look at those three global products, it would give you lots of insights and what you do in a certain sector can be massively impacted. I’m surprised that having worked in the field, in headquarters, now back in the field, that sometimes even people within UNICEF are not familiar with these kinds of tools and guidance. It still remains very limited and there is no incentive for many of them to go searching for those insights and lessons out there. So how do we clear that culture with other people to go looking for that knowledge and trying to shape what they do with those tools and guidance available.