The impact of national and international crises and disasters on population mental
health has been well established, with poorer mental health and a higher incidence
of mental disorders documented during war and armed conflict (Charlson et al., 2019),
political instability and anti-government protests (Kai Hou et al., 2015), natural
disasters (Makwana, 2019), economic crises (Bartoll et al., 2013), mass displacement
(Morina et al., 2018), and linked more broadly to inequality, poverty and social injustices
(Lund et al., 2010). Following the COVID-19 pandemic, mental health has been highlighted
as a global priority in response to the fallout of the crisis, with the toll of lockdown,
loss of jobs, increase in domestic violence, and lower social support impacting the
wellbeing and functioning of affected populations (Holmes et al., 2020; UNHCR, 2020a;
WHO, 2020). Research has shown that such crises, particularly when chronic, have an
impact beyond the experience of the individual, affecting the functioning of families,
communities, and wider social structures and socio-political systems (Sousa, 2013;
Somasundaram, 2014). Despite major advances in the development and implementation
of interventions in responding to crises and emergencies, there remain significant
gaps in the evidence-base for public mental health responses that are sufficiently
contextualized to this collective suffering.
The collective in existing models of mental health and care
Psychological literature has tended to focus on singular experiences and associated
individualized interventions, neglecting wider social systems and interpersonal processes
(Maercker and Horn, 2013). Widely used psychological models of post-traumatic stress
disorder (PTSD), for instance, have major conceptual limitations when applied in the
context of humanitarian disasters, chronic instability, inequality, and social injustice.
Such models have been developed for the most part in European or North American populations
at the individual level. They generally assume a certain level of current safety,
a clear distinction between pre- and post-trauma, and that hypervigilance and a sense
of current threat are maladaptive symptoms linked to the over appraisal of danger
and poor integration of trauma memories (Foa et al., 1989; Ehlers and Clark, 2000).
They have limitations, therefore, in their application to populations facing ongoing
and very real threats of violence and loss. Indeed, the application of psychological
models of trauma to war affected populations has been heavily criticized because it
risks imposing an individual approach inappropriate to the context of collective trauma
(Wessells, 2009), and undermining natural and normal reactions to complex instability
and violence (Summerfield, 2000).
Within displaced Palestinian populations, local idioms of distress that reflect collective
suffering and social distress provide documentation of broader conceptualizations
of mental health and coping. Words like somoud (strength in adversity or steadfastness)
express the resilience of the collective, and words like sadma (shock), faji'a (tragedy),
and musiba (calamity) communicate a range of collective trauma experiences (Giacaman
et al., 2011). To attempt to apply individualist and medicalized binary categories
of mental disorders to this collective distress so tightly intertwined with oppression
and injustice, is to oversimplify mental health and to neglect contextualized and
collective experience. Such individualized simplifications can also lead to missing
other mechanisms that are key for understanding and mitigating psychological distress
in context. Research in conflict-affected populations has consistently shown strong
mitigating factors of interpersonal relationships (Bosqui et al., 2017), social support
(Besser and Neria, 2012), collective cohesion and action (Greenley et al., 1975),
and social equality and justice (Burns and Esterhuizen, 2008), through a fluid process
of community resilience in which ‘cultural, political, and social factors interact
in the face of adverse conditions’ (Nuwayid et al., 2011, p. 507). Community resilience
is the cooperative and collective pooling of resources that enables coping, at the
collective and individual levels, in the context of major events or changes, unpredictability,
and uncertainty (Berkes and Ross, 2013; Somasundaram and Sivayokan, 2013). The mechanisms
underlying community resilience are not included in traditional models of stress that
are predominantly grounded in cognitive or behavioral theories, and tested in populations
in relative safety and security. More recent socio-interpersonal models of PTSD have
attempted to integrate social and individual processes into our understanding of trauma
reactions (Maercker and Horn, 2013). It is imperative, more than ever during the current
pandemic, that this integration of broader community, collective, and systemic perspectives
on mental health is used to inform mental health and psychosocial support for crisis-affected
populations.
The international guidelines for mental health and psychosocial support in humanitarian
emergencies recommends a tiered model of care, which includes a strong focus on interventions
at the basic services and security, family and community support, and focused psychosocial
support levels, that is responsive to context and culture, and builds on existing
resources (IASC, 2007). Specialized mental health care is only a small part of this
model, dedicated to treating clinical disorders and delivered by trained professionals.
The evidence-base however, remains thin at the broader levels of intervention, with
the strongest evidence for specialist and focused service provision. A review of evidence
found that specialized and focused psychosocial support in emergency and humanitarian
settings was supported by multiple randomized control trials, while only a handful
supported family and community support, and no trials were published on interventions
at the basic services and security level (Tol et al., 2013). This means that the levels
of intervention that reach the most people and address collective experiences are
the least well established. These levels may include advocacy, community-led initiatives,
preventative interventions, activating social networks, and communal traditional support
(Nuwayid et al., 2011; Somasundaram, 2014). Even with the growing evidence for family
and community support, many interventions remain limited to the diluted application
of cognitive and behavioral models of intervention developed in non-crisis affected
countries by specialist clinical providers (Bosqui and Marshoud, 2018), while multi-layered
care systems that integrate community, family, and individual components are poorly
supported (Tol et al., 2011; Betancourt et al., 2013). This is problematic because
the current evidence-base neglects broader interpersonal processes and collective
experiences that could be instrumental to mitigate harm. There is a clear need for
the development and empirical testing of social change and community based interventions,
that include family and community components, and that are contextualized, feasible,
and sustainable in crisis settings.
Learning from crisis-hit Lebanon
Lebanon is a middle-income country reeling from a dual explosion in the port of Beirut
that ripped through the city killing hundreds, injuring thousands, and displacing
hundreds of thousands. The blasts, known locally as the port explosions or disaster,
the bombing of Beirut, or the Beirut massacre, were blamed on explosive materials,
including more than 2700 tons of ammonium nitrate, improperly stored for years despite
warnings of its lethal capacity. The explosions come at a time when the country was
already facing an economic disaster of a scale not seen since the civil war. The economic
crisis, linked to decades of state corruption, triggered a popular uprising, or thawra
(revolution), in October 2019. Hundreds of thousands of people took to the street,
united across sectarian lines to demand system reform, an end to corruption, and improved
social equality and human rights. Lebanon is the third highest indebted country in
the world, and has one of the highest income inequality distributions; 2% of the population
earns the same as over 60% of the entire population (UNDP, 2017). In addition, Lebanon
has been affected by a refugee crisis, with a government estimated 1.5 million refugees
in a total population of around 5.5 million (UNHCR, 2020b). Refugees in Lebanon suffer
from poor educational and economic opportunities, socio-economic insecurity, and widespread
prejudice and discrimination (WHO, 2017). Other migrant groups brought to the country
through the notorious kafala (sponsorship) system to work as domestic workers, face
other challenges through restrictions of movement and personal freedoms, as well as
exploitation and mistreatment by employers (Fernandez, 2018).
The painful impact of the worsening economic crisis in Lebanon has begun to take its
toll on many residents, with loss in incomes and the closure of businesses widespread.
Lebanon's unemployment rate has soared, with well over a third of the Lebanese population
living below the poverty line (World Bank, 2020). For some refugee populations, this
figure is closer to 90% (UNHCR, 2020b). The first COVID-19 positive patient was diagnosed
in Lebanon in late February 2020, and the Lebanese government swiftly introduced social
distancing measures by shutting down schools, universities, parks, shops, restaurants,
and cinemas. With increasing cases of COVID-19, a whole country lockdown was introduced
in mid-March 2020, including the closures of the airport, port, and borders, as well
as strict rules on wearing masks outdoors and a nighttime curfew, enforced by a heavy
police and army presence. The inability of daily workers to earn a salary, mixed with
price increases through the sharp devaluation of the Lebanese Lira, and a severely
limited social welfare system, put many residents at risk of life-threatening hardship
(Devi, 2020). The Beirut port explosions have spiraled the country into further pain,
and re-ignited anger over the corruption and incompetence of the ruling elite. The
devastation of Beirut and its people, the COVID-19 pandemic, and the worsening economic
crisis is a disaster for Lebanon on a scale that we have yet to comprehend. The socio-political,
public health, and economic crises have and will lead to further losses and deteriorating
quality of life – Lebanon is facing an extraordinary strain on individual, family,
community, and national coping resources.
Collective suffering, and resilience, has been well documented throughout past crises
in Lebanon. During the July 2006 war, collective experiences of the war were found
to be significantly associated with anxiety symptoms, regardless of individual exposure
(Yamout and Chaaya, 2011), and with action-orientated or risk taking behaviors (Karam
et al., 2007). In the aftermath of the port explosions, action-oriented behaviors
have been observed, with hundreds of volunteers from all over the country providing
help to clear debris, cover broken windows and doors, and offer water, food and shelter
to affected people (An-Nahar, 2020). The collective processing of events, through
the sharing of stories, videos, and CCTV footage, has also been intensely observed
in the days and weeks following the explosion. Experiences during the 2006 war were
found to be associated not just with distress, but with community resilience, when
such experiences were comprised of community cohesiveness, a shared identity, and
social support. Adequate public health interventions and social solidarity were found
to help sustain this resilience over time (Nuwayid et al., 2011). The current provision
of mental health care in Lebanon is predominantly through the private health care
system for which many low-income and marginalized people have no access (WHO, 2017).
However, the Ministry of Public Health launched the National Mental Health Program
in 2014, and a 5-year Mental Health and Substance Use Strategy with the aim of reforming
the Mental Health System in line with WHO global action plan for Mental Health 2013–2020
(Karam et al., 2016). Much has been achieved, including training primary care workers,
rolling out evidence-based treatments (De Almeida and Saraceno, 2018), and improving
the integration and accessibility of services for Syrian refugees (El Chammay et al.,
2016). The program has also supported research, such as projects that aim to improve
access to the WHO's Problem Management Plus program using technology (Shehadeh et
al., 2020), scale up similar programs for children and adolescents (Brown et al.,
2019), and develop family focused psychosocial support for at-risk young people drawing
on existing family and community knowledge (Bosqui et al., 2020). In response to the
COVID-19 crisis a coordinated plan was developed with WHO and UNICEF, in line with
IASC guidelines (NMHP, 2020a), that aimed to use the crisis as an opportunity to strengthen
system reform grounded in community participation and human rights (El Chammay and
Roberts, 2020). Then, in response to the Beirut port explosions, a national action
plan was developed within days of the explosions, focusing on doing no harm and coordinating
multiple local and international agencies responses to the overwhelming mental health
needs of the population (NMHP, 2020b). These are strong examples of a public health
approach that engages and supports communities, responds to changes in context, and
attempts to address community or population level distress. Gaps remain however, in
the evidence-base for family and community interventions, as well as at the level
of basic services and security in the context of the current collective loss and community
distress. The impact of the devastating explosions, economic crisis, and persistent
government corruption and mismanagement, has created a palpable sense of chronic uncertainty,
anger, and collective anxiety in the country. While major strides have been taken
in improving access to evidence-based care, attention to the needs of the collective
are imperative to mitigate the mental health consequences of the worst crises in Lebanon
since the civil war.
The need to shift to a contextualized and collective mental health paradigm
The snowballing crises and collective distress in Lebanon, serve to demonstrate the
limitations of individualistic clinical models and the strengths of a community and
systemic public health approach. Other countries affected by significant collective
emergencies, crises or pervasive social inequalities, including high-income countries,
could benefit from this altered approach. This is not to disregard neurobiological,
genetic, cognitive, or behavioral influences on mental health, but to acknowledge
the major impacts of social and economic context, and to incorporate this into our
models of understanding, and public mental health responses. The current global COVID-19
pandemic is no exception, mental health services will grapple to function if they
maintain provision at the individual level and neglect the wider ecological system
levels of family, community, and country. We know that social adversity, injustice,
inequality, poverty, and chronic stress exposure, are strongly linked to increased
mental health difficulties (Lund et al., 2010), and correspondingly that social cohesion
and community resilience can buffer the impact of national crises (Nuwayid et al.,
2011). Yet, models of understanding, service structures, and interventions in many
country contexts remain largely grounded in medical frameworks and individualized
treatment. A shift to a contextualized and collective mental health paradigm can help
to integrate evidence at every ecological level, and to respond to changes in context.
The neglect of such an integrated approach, in theory and practice, can otherwise
feed into, and replicate, tragic mental health and health inequalities. The shift
to a contextualized and collective mental health paradigm, alongside improving the
evidence-base and implementation of multi-layered systemic interventions, can help
to address this tragedy, and inform a shift in current mental health service policy
and provision during, and beyond, these crises.