Guidelines for Programmes
Psychosocial and Mental Health Care Assistance 
in (Post) Disaster 
and Conflict Areas.


Review and Critique on:

Guidelines for Programmes
Psychosocial and Mental Health Care Assistance 
in (Post) Disaster 
and Conflict Areas.





In the left (yellow) column of this document, 
you will find the original text of the draft text
" Guidelines for Programmes Psychosocial 
and Mental Health Care Assistance 
in (Post) Disaster 
and Conflict Areas."
as it can also be found on the site of 
the International Centre of the Netherlands Institute for Care and Welfare.

Incidentally I have highlighted portions of this text in red.
When I refer to this text, I will do this as follows:
<=This text, or <=this document, or <=these guidelines.
The reason for the use of the (<=) symbol is that I will have to refer to several other texts and guideline-documents, so it is easy to get confused.

In this column (The blue column), you will find my remarks.

This document is a publication of the Netherlands Institute for Care and Welfare, and all rights are reserved by the Institute. The document may, however, be freely reviewed, abstracted, reproduced and translated, in part or in whole, but not for sale nor for use in conjunction with commercial purposes.

This publication was made possible by subsidies from

  • The Ministry of Foreign Affairs, specifically the Directorate General for International Co-operation, of the Netherlands
  • Médecins Sans Frontières, the Netherlands
  • War Trauma Foundation International
  • The International Centre of the Netherlands Institute for Care and Welfare.

Author: Mrs. Petra G. H. Aarts, 
Aarts psychotrauma, research, advice & training, 

My critique is based on my work in Croatia/Bosnia, Ethiopia, and Cambodia in the period 1992-1999. In this period I worked partly as a volunteer, partly as an employee of one of the organisations (TPO) that endorse the guidelines that I review here, and partly as an independent project initiator for WHO and for the Dutch Ministry of Foreign Affairs.

During this period I have met many of the 'players' in the field of Mental Health Care, as well as in general Humanitarian Aid.

My field is the Transfer of Ideology between Generations, and, more specific for this document, the transfer of Collective Trauma as a stage in the Cycle of Armed Conflict and the development of Intervention-projects to break this cycle. It is from this point of view that I give my reaction to <=this document of the NIZW

This publication can be ordered from:
International Centre
Netherlands Institute for Care and Welfare
Postbox 19152
3501 DD Utrecht
The Netherlands
tel (0031) 30 2306552
fax (0031) 30 2306540
email to:

These draft guidelines are endorsed by
  • Advisory Committee on Psychosocial Care,
  • Ministry of Foreign Affairs of the Netherlands
  • Médecins Sans Frontières, Dutch section
  • Cordaid, the Netherlands
  • Dutch Relief and Rehabilitation Agency
  • HealthNet International, the Netherlands
  • Pharos, the Netherlands
  • The Netherlands Red Cross
  • Dutch Refugee Foundation

  • Transcultural Psychosocial Organization, the Netherlands


This publication was produced under the auspices of the International Centre of the Netherlands Institute for Care and Welfare.
The guidelines have been formulated by Mrs. Petra G.H. Aarts, in collaboration with

  • Mr Pim de Graaf, International Centre, Netherlands Institute for Care and Welfare
  • Mr Kaz de Jong, Médecins Sans Frontières, Dutch section
  • Prof. Rolf Kleber, PhD, Department of clinical psychology, Utrecht University, the Netherlands
  • Mr Willem van de Put, HealthNet International, Amsterdam, the Netherlands
The contribution of the following persons to the development of these guidelines is gratefully acknowledged:
Mrs. Loes van Willigen, MD, PhD
Mrs. Geertrui Kortmann, PhD
Prof. Mrs. Annemiek Richters, PhD
Mr. Frans van den Boom, PhD

These draft guidelines are circulated worldwide. It is expected that, through a process of organised consultation throughout 2001, an improved version will be published in 2002.
Your comments and suggestions are welcome. Please send them to: under the subject “guidelines”.
This document can be downloaded from



1. Introduction  11
2. Psychosocial Assistance and Mental Health Care 13
3. Guidelines 15
4. The guidelines 
Preparation, Co-ordination and Co-operation
Target Group(s) 18
Planning, Phasing and Exit Strategy  19
Goals, Interventions and Methods 20
Political, Ethnic, Cultural and Religious 
Project Evaluation 25
Scientific Research 26
Literature  29

1.  Introduction

Modern day conflicts and wars are numerous and often extremely cruel. As such they are a serious threat to the health and well being of millions of people. According to the United Nations, there are currently more than forty million refugees, internally displaced persons and other victims of violence . Modern warfare, armed conflicts, repression, but also natural or industrial disasters are not just a threat in the physical sense, but may also lead to despair and moral disintegration.
The last decades have seen a steady increase in the level of humanitarian aid to victims. Until recently, this aid primarily took the form of medical care and the provision of material resources, such as food and shelter. However, disasters and violence can also leave their mark in terms of psychological damage. For these reasons, humanitarian aid can not be limited to material support.

The problems faced by large groups of people are characterised by loss: loss of kin and home, of the opportunity to generate an income, of social cohesion, of human dignity, of trust and safety, of a positive self image and of a perspective of the future. People often have to live under conditions of near total dependence. The pre-existing social fabric is often torn. Therefore, the interhuman relationships, which could otherwise serve to provide mutual support, are disrupted. The losses further impede the possibilities for restoring mental equilibrium following traumatic experiences. Moreover, in many cases there is an on-going threat to life and limb.
Long-term exposure to stressful and abnormal conditions – as is the case with most refugees and victims of violence – has a negative impact on a person’s (mental) health, behavior and ability to function. To date it is considered to be a basic human responsibility to ease the suffering, increase the chance of survival and provide relief to the more than forty million refugees and displaced persons.
Within the international community, this insight has led to the development and implementation of various projects aimed at psychosocial assistance and mental health care to survivors of man-made or natural violence. Given the background of the previous neglect of the  psychological and social consequences of violence, these initiatives are encouraging. 

In General it is unclear on what base <=this document gathers the consequences of natural disasters and those of Armed Conflict in one single frame of analysis. Especially seen from the viewpoint of mental health I feel that a clear difference should be made, certainly in the analysis, but most probably also in the practical approach. My remarks here focus on the field of communities after armed conflict.

The fact that survivors of both kinds of disasters are seen as one is probably a direct consequence of the western 'help-approach' that is basically geared to 'victims' in stead of to 'being an agent in recovery'. As an illustration I have highlighted the use of the word 'victims' in the text at the left. In our Western Ideology, our help-reflex is mainly geared towards 'victims'. Victims are, in this ideology, inherently 'innocent', and they 'suffer'. As you can clearly read from the introduction  'innocent suffering' is what seems to unite victims of 'natural and man-made disaster', and 'innocent suffering' is what entitles them to our support.

Yet, I would like to propose here that in 'man-made disaster' the concept of 'innocence' is useless and even dangerous. As we can clearly see in most conflicts that exist world-wide, they are not incidents, but they are episodes in a cycle that sees periods of violence and periods of relative 'peace'. Parties in these conflicts have the tendency to switch roles of 'victim' and 'perpetrator' in the eye of the western comments.

In this aspect, Armed Conflict and Natural Disaster differ. In most natural disaster we may be able to speak about 'innocent victims', although here too, we may sometimes doubt the natural origins of 'natural disasters'. 1)

The concept of 'innocence' is dangerous, because it deprives people of their responsibility, of their active role in the onset of conflicts, and hence it usually denies an essential aspect of the identity of the 'victims'. Our Western help-system, by projecting 'innocence' in the subjects of their efforts, imposes the role of innocent victims on these subjects who have to comply in order to qualify for help. In doing so, the effect is that the subjects effectively re-arrange their identity as to be innocent. In this process usually a process of falsifying history (and in this, falsifying personal as well as collective memories) is started, and the result is exacerbating the loss of identity that is so damaging to the very same people that we try to 'help'.


The downside of the current interest in these forms of aid is that there appears to be an explosive growth in projects without the necessary co-ordination or quality assurance.
The required knowledge and skills to provide this care under usually complex conditions are as yet not sufficiently developed or founded. It is therefore very important that internationally approved criteria will be developed to improve the quality of these forms of aid and to promote their effectiveness. It is of fundamental importance that guidelines and good practices for psychosocial and mental health care to those who are affected by war and natural disasters, are developed and that they are sufficiently sensitive to cultural differences.

These guidelines have been formulated by and for organisations involved in providing these kinds of care for refugees, displaced persons, and victims of violence or natural disasters. They are also of importance to donors. The guidelines can be applied as test criteria for donors and institutions, or for anyone responsible for assessing psychosocial and mental health care projects.

The (draft) guidelines described below are not just aimed at promoting quality psychosocial interventions and mental health care, but also at stimulating new initiatives in this field.

September 2000

Petra G. H. Aarts

Here we come to a crucial paragraph. 
The question is: Why these guide-lines?

At least two general approaches for guidelines can be imagined: the first being that groups of organisers agree on guidelines for themselves. The set a series of criteria to judge their own work, and they try to abide by them.
A second approach is as an attempt to control  projects of other organisations . In stead of creating an open discussion about the merit of specific approaches, this second policy is covert. It aims at introducing criteria on a meta-level, after which the discussion is no longer between the people that actually work in the field, but in the hands of funders and governmental institutions. 

The text here mentions "An explosive growth in projects without the necessary co-ordination or quality assurance". Since the organisations that endorse <=this draft document probably do not refer to themselves in this sentence, it is clear that these guidelines have the second objective.

<=This text mimics an outsiders-approach to the field. 
It pretends to be ignorant of the fact that there is A) a competition going on between several groups of providers of mental health care that know each other very well, and B) about the structural competition between 'established' organisations and incidental initiatives.

A) Instances of competing main players are for instance the IRCT,
the Norwegian Psykososialt senter for flyktninger in Co-operation with IOM , the  HPRT ( another site on HRPT), the combined ITSP (New York) and IRCT (Copenhagen), and the MFCVT (London), to name some that should have been mentioned.
As you will see these organisations operate alongside each other in the same countries and ignore each other at best, or worse, obstruct each other's work. I know this from my personal experience, working in a project that was originally placed by the Dutch Government under the umbrella of TPO , one of the organisations that endorses the guidelines that are proposed here.. 

Guidelines that do not consider this damaging competition, and try to bridge the controversies that exist on this level of the field, can only be seen as instruments in this controversy, as they in their turn ignore comparable documents like the 'Tokyo Guidelines for Trauma and Reconstruction' ( Draft Conclusions and Recommendations ) developed in 1999, or, an even more significant omission, a publication like The Impact of War and Atrocity on Civilian Populations: Basic Principles for NGO Interventions and a Critique of Psychosocial Trauma Projects , by Derek Summerfield (MFCVT, 1996)
Furthertmore, there is now the WHO document:

B) There is, especially in the chaotic situations  during and after armed conflict, a structural tension between 'incidental initiatives' and institutional organisations in the help-industry. Incidental projects tend to be set-up by (small groups of) all-round individuals, Jack-of all trades, that are on 'the right spot at the right moment'. These projects have a tendency to make the most out of minimal resources, and usually describe the established organisations as wasting money on huge overhead, corruption, and incapacity.
On the other hand, there are the established organisations that are 'prepared' for emergencies, and work according to manuals, or general policies. They tend to initiate a new project based on generalised information from earlier experience, and accuse 'incidental initiatives' to be 'unorganised and lacking quality'.

C) Finally this document is not talking about the relationship between general organisations in humanitarian aid and the organisations 'specialised' in Mental Health and Psychosocial Care. This also is a serious omission, because mental health in (post) war situations is greatly influenced by the way that humanitarian aid is allocated. It is often said that the Help-industry is a second disaster overpowering people after the first disaster. All help during and after armed conflict has political implications, and political consequences immediately translate into psychosocial conditions in the life of refugees. All help has ideological components that are more or less at odds with other helping organisations and with the ideology of those that are being helped. 

2. Psychosocial Assistance and Mental Health Care

Current psychosocial aid and mental health care concentrate largely on strengthening or restoring a new social balance and on individual rehabilitation. Both forms of care are not only important to the well-being and health of individuals or groups of individuals, but also in terms of providing opportunities for social, economic and political stabilisation.

The concepts of psychosocial care and mental health care usually overlap within international humanitarian aid services. In practice, both psychosocial support and mental health care strive to prevent psychological problems and to provide counseling to people who live in situations that threaten their mental balance. Mental health care, however, also provides treatment of possible pathological reactions. A broad-brush distinction has been made for the purposes of these guidelines, whereby the premise is that the specialised care of (posttraumatic) mental disorders is part of mental health care and falls outside the scope of psychosocial care.

In (post) disaster and conflict areas a smaller part of the population will respond with pathological reactions, including depression, psychotic reactions, post-traumatic stress disorder and other anxiety disorders, depending on the duration and intensity of the events. In most cases the regular local care systems are not equipped to provide adequate care for these people. For this reason it is necessary to support and (re)build the local mental health care system so that it can provide specialist care.
As may be expected, the majority of the population will exhibit normal – in the sense of non-pathological – symptoms when faced with shocking events and stressful circumstances. However, the social bonds and structures capable of providing help and mutual support have often been lost.

Psychosocial care deals with a broad range of psychosocial problems and so promotes the restoration of social cohesion and infrastructure, as well as the independence and dignity of individuals and groups. It serves to prevent pathological developments and further social dislocation. Such an approach requires amongst others psychological, historical, medical and anthropological insights. Psychosocial care for the victims of war and natural disasters demands, by definition, a multidisciplinary approach.
Adequate psychosocial care cannot be limited to a one-sided emphasis on the ‘working through’ of traumatic experiences. Overemphasising pathology reinforces dependence, victimhood and powerlessness, at the expense of coping capacities. It goes without saying that this is not beneficial to the communities.

In (post) disaster and conflict areas mental health care and psychosocial aid should be provided side by side, though not necessarily by the same organisation. Co-ordination and co-operation between both specific forms of humanitarian aid is crucial, as is the development of insight into the cultural context within which the aid will be given.

In <=this paragraph the endorsing organisations carve out a territory for themselves, a 'niche' in the market of the 'help-industry', without giving any foundation. In fact, they postulate their own functionality, where they should, at first, respond to the considerable critique that has also recently been growing. 
One of the early critics on the construct of posttraumatic 'disease' is Thomas Szasz, for instance in 'Insanity: The Idea and its Consequences' (1987), and recently in 'Is Mental Illness a Disease?' (2001). Many other critical publications on PTSD were published, see: The invention of PTSD by Dr. Ellie Lee (and are cynically illustrated for instance by the PTSD-Claim Handbook , by American Forces Vietnam Network "AFVN") 
More specific, in the case of posttraumatic effects after armed conflict, the 'Guidelines for treatment of PTSD' by E.B.Foa et. al. (Journal of Traumatic Stress, 2000, vol. 4) states that there is so little conclusive research or evidence to show the effect of interventions in this field after armed conflict and especially in non-industrialized countries, that they did not include any guidelines in this field.
Very critical are also Bracken & Petty, in Rethinking the Trauma of War (1998). Although this title is mentioned in the (very short) paragraph 'literature' at the end of <=this document, there is no sign that the content of this book has influenced <=this document at all- at the contrary.
The most appropriate document that should have been addressed here, however, is 'A Critique of seven assumptions behind psychological trauma programmes in War-affected areas ', by Dr. D. Summerfield (1999).
(abstract and 7 assumptions here .) 

<=This document is defining here two types of programmes (As also announced in the title):

A) Psychosocial Care, and 
B) Mental Health Care.

It then describes a wide range of expertise, needed for Psychosocial Care, but it does not do so for Mental health Care.Strange enough, the 'working through' of traumatic experiences seems to be included in psychosocial, rather than in Mental health care.

The WHO declaration states on this topic:
"(...)community-based, psychosocial, phase-specific, cultural and gender-sensitive programmes must be given first priority when establishing or reconstructing mental health care systems.  They should bridge in a coherent way emergency response to development. Specialised clinical interventions responding to individual needs are limited.  They must be balanced, because they respond to the needs of a few, may possibly become stigmatizing, tackle problems in isolation, are expensive and non-sustainable.(...)" (article 3)

3.  Guidelines

These guidelines for psychosocial and mental health care pertain to practical aspects of national and international support for survivors of violence or disasters. They support the design, implementation and evaluation of psychosocial projects and of scientific research. They are the result of a basic consensus about standards for good practices and ethical values, regardless of the country or region receiving the aid.

By definition, guidelines are broad and general in nature, whereas the target group(s) and the circumstances under which the care must be provided are always unique as well as complex. Therefore, the guidelines do not provide an unambiguous answer to every specific situation. Nor do they define what type of intervention is needed to achieve a particular goal against a specific cultural background. The underlying assumption is that every organisation active in this field has the necessary knowledge and insights to develop high quality and responsible interventions.

The guidelines provide the standards and frameworks that can be used to develop psychosocial and mental health care projects and programmes. They are a set of standards pertaining to the practical aspects of providing multilateral or bilateral aid to refugees, internally displaced persons, and other victims of violence or natural disasters. They are not a starting point or framework for the more general social, political or strategic policy for governments or (inter) national non-governmental organisations (NGOs) with respect to the overall position of the target group(s).

Naturally psychosocial and mental health care in (post) disaster and conflict areas are subject to the same implementation criteria as all other forms of humanitarian aid. These criteria are:

  • The goals must be pertinent to the needs of the target group(s);
  • The aid must reach the greatest number possible of people within the target group (coverage);
  • The aid must be provided on a continuous basis for as long as it is needed;
  • The interventions must be effective;
  • There must be equal access for all members of the target group (equity); and
  • The aid must strengthen and utilise the local capacity.
The guidelines proper are grouped in different rubrics and preceded by a general guideline or standard. The numbering of the guidelines is not an indication of priority.
This chapter concludes in a set of criteria that seem rather obvious, however they are much less so after some consideration. Let us start by considering some questions that may be asked for each of these criteria: 
  • The goals must be pertinent to the needs of the target group(s);
One should ask here: ' Needs' according to which set of values? Are these the needs as felt by the target groups? Usually these groups do not feel any need for projects in the field of mental health. Especially after armed conflict needs are usually expressed in terms of 'money and arms.' 
They are also not the needs that are usually defined by the international emergency organisations that provide water, food, shelter and emergency health care in such a way that mental health is seriously affected.
The organizers of <== this document clearly refer to 'needs' as perceived by themselves, 'for the good of the target groups'. This is not in itself wrong, but it is clear that such a definition must be elaborated upon, certainly in the light of the critiques as mentioned above.
  • The aid must reach the greatest number possible of people within the target group (coverage);
This criterium should be rejected altogether. In the light of what is later said (exit strategy), the target must be that a id must be a temporary period that has to be restricted as much as possible. Projects should, in my opinion (and I have shown that this is possible) have an initiating effect, where the target population should be empowered to take over as soon as possible. The criterium should therefore be something like: Support in the form of 'aid' should be designed to reach the fewest possible number people of the target group in order to create a self-continuing effect within the target group.
  • The aid must be provided on a continuous basis for as long as it is needed;
Again: 'needed' by whom? In my experience the target group will immediately start 'needing' the aid, and will go on 'needing' it as long as it may be provided. Without an appropriate definition of 'aid' , this kind of 'criteria' is senseless.
  • The interventions must be effective
This seems indisputable. However, again, the question is not only 'what is effective', since no valid criteria for effectiveness have ever been developed for mental-health projects, but also the perception of effectiveness differs structurally between members of the target group, members of International organisations, and members of the intervention teams.
  • There must be equal access for all members of the target group (equity);
A good example of the impracticability of western ideas in real implementation. In reality there is never equal access. In general programmes, for instance one sees that women, or children have less access. In reaction to this, one can redefine the target group. Within the target group again, one will see differences in education, poverty, religion, that influence participation. Always one chooses to support specific groups, and doing so the other groups will see their access limited. This discrimination is essential for every project, and can not be escaped. A guideline here should be that one has to be aware of these inequalities, and be able to explain the choices that have been made. (To attack these choices is a favorite activity between competing projects.)
  • The aid must strengthen and utilise the local capacity.
Interesting is not only that this criterium is named as the last, but also the wording. ' Aid' is used as an actor that 'does' things, notably it 'uses' local capacity. One wonders how much thinking has gone into this wording. There are many variables influencing the relationship between 'local capacity' and the organisations that carry 'aid' into any given situation. Especially in the field of mental health, 'aid' is an extremely difficult concept, because the agent that 'controls' the 'aid' is blocking its own objectives exactly because of this fact. (See e.g. Lyotard's paradox )

The fact is that 'local capacity' is usually only 'used', which means that the 'aid' experts are in control, and do not leave this position. Strengthening local capacity usually means 'training in the ideologically colored instruments that are deemed functional by the aid-giver'.

So we see how these seemingly logic criteria are in fact hollow sentences, created by western cliché's, in a quasi-intellectual atmosphere devoid of real practice. This is strange, since I know for a fact that some of the organisations that endorse these guidelines are indeed well aware of the practical problems with this kind of guidelines.


  • 4. The guidelines



    Preparation, Co-ordination and Co-operation

    General standard
    Every project requires thorough preparation. Hence sufficiently reliable information must be collected beforehand concerning:

    • The scope, condition and needs of the target group;
    • The capacity and quality of local support and health care organisations;
    • The needs of those organisations;
    • The cultural, political, historical, ethnic, and religious context of the target group and of the society in which the target group finds itself;
    • The activities and plans of other, including local, (aid) organisations.
    The insights gained from this information are essential prerequisites of any intervention. It is obvious that the project staff must have the necessary skills and knowledge of (post) traumatic reactions and symptoms, psychosocial or mental health care, and in intervention methods.

    Specific guidelines

    1 The preparation phase should make as much use as possible of (assessment) data that have already been, or will be  collected by other aid organisations.

    2     Co-ordination and consultation with other aid organisations and local governments is vital for achieving the maximum in terms of the quality and scope of psychosocial and mental health care.

    3     The definition of the target group(s), the goal(s) and the intervention methods must be done in consultation with other (aid) organisations and representatives of the target group.

    4     Aid organisations should work under the umbrella of the local co-ordinating activities of other organisations or governments, unless it is clear that it is in the interest of the target group to deviate from this principle.

    5    A project that is primarily concerned with psychopathology and the improvement of mental health care should, as far as possible, co-operate and co-ordinate with the regular mental health care system and the authorities involved.

    The 'guidelines' in this chapter begin to ignore the fact that intervention in a community after armed conflict (and after natural disaster as well?) is inherently chaotic in nature. Not only are the feelings of the population in turmoil, but also many different international agents, with different ideologies jump in and compete with each other. The non-sensical character of the 'thorough preparation' - approach in this chapter is well illustrated by the first specific guideline: 
    The preparation phase should make as much use as possible of (assessment) data that (...) will be  collected by other aid organisations.
    In situations after armed conflict all data are fluid and unreliable. Data that existed before the conflict, even if the conflict was relatively 'short' in time, are distorted by all kinds of processes, and the current reality is usually like quicksand. In any case, intervention in these situations is an action in a highly volatile situation. The fact that there is no mention of this, and that the 'guidelines' seem to ignore this completely makes this chapter again hollow.

    Target Group(s)

    General standard
    Preferably, psychosocial aid or mental health care is offered to the entire community of survivors of violence and natural disasters. There may, however, often be a need for special care for vulnerable groups such as children, adolescents, women, the handicapped, elderly people, veterans or victims of torture, or (sexual) violence.

    Specific guidelines
    6     The selection and identification of vulnerable groups must be done in consultation with key local representatives and institutions and in conjunction with other national and international aid organisations.

    7     Organisations must ensure that their interventions do not contribute to or worsen any friction and rivalry within the target group communities or with their immediate environment.

    8     Where refugees are housed within a host community, the host community must be provided with adequate information. Key persons from the host community must be involved in the reasons and planning of the aid interventions.

    9     If there is more than one organisation concentrating on a particular target group, these organisations must do so in co-operation and consultation with each other.

    10    Groups or individuals must not become stigmatised or unnecessarily medicalised, nor should their trust be broken.

    As we saw before end as we see again in the next chapter, <= these guidelines tend to prepare the way for 'aid-projects to take over the whole mental health system in a community after an emergency. Of course, mental health care should be available to 'the entire community', this seems obvious, but it is highly questionable if this is the task of any outsiders assistance after some form of emergency, let alone that this is 'preferable' as is stated <=here
    Mental health care is highly culturally sensitive, and should therefore be defined by and within the community itself. There are (there may be) instances in which after some form of disaster, outside help is required, but certainly it should not be the task of outside experts to rethink and set up the entire mental health care system.
    To define 'target' groups in terms of 'vulnerability' is, again, spurious. There are many other reasons for the definition of target groups as should have been discussed in the chapter about  'exit strategy' . 

    Since it is obviously not the place of an outsiders initiative to target the whole community, the target group(s) should also be defined in terms of strength: those that can most easily and quickly take over the initiative and translate it 'into' the community.


    6: Target groups are usually predefined, as the writers of <= this document should well know. Organisations as UNICEF target children by their mandate, etc.
    7: It is interesting that <= this document mentions rivalry between target groups but is silent about the rivalry between the international organisations that target these groups. More often than not, the friction that is referred to is a mirror of the friction between the IO's that support these different target groups.
    8: But what if the host community is downright hostile against the refugees?
    9: But what if these organisations do not agree which each other on the best way to work? This is usually the case, or else these organisations would merge, as currently is happening within OXFAM, or Save the Children, for instance. 
    10: 'Trauma' is a medical label, involving the diagnosis of pathology. Since <= this whole text defines the communities to be supported as 'victims', 'vulnerable', traumatized, etc. this advice is necessarily hollow.
    A reconsidering ot the 'trauma' concept would be necessary in order to prevent medicalisation and stigmatisation. 
    Also the matter of 'trust' that is inserted here is dangerous. It should be noted how conspicuously this is done here, where the matter of Trust deserves maybe a chapter of its own. 
    'Trust' is by no means a matter of essence, and a community may be very right not to 'trust' too much. Inviting trust is therefore usually another step in creating dependency within  the 'target' population, since 'trust' and 'control' are sides of the same coin. Why should they be invited to trust? It may be much better to describe guidelines on how to operate outside trust from the beginning, keeping 'control' with the target group, or bringing control to the target group as fast as possible.

    Planning, Phasing and Exit Strategies

    General standard
    The goal of psychosocial and mental health care is to provide support and relief to people and communities that are forced to live with the physical, mental and material consequences of violence, suppression or disasters, under circumstances that often constitute a continued threat to human integrity and dignity. Humanitarian aid can only be limited to a brief period of time in those countries where the quality and capacity of the care system in principle is sufficient. In the vast majority of cases, however, longer-lasting and more structural aid will be required. Psychosocial assistance and mental health care can therefore be seen as a necessary bridge between humanitarian aid and development co-operation.

    Specific guidelines
    11     Both the psychosocial aid and the mental health care must focus on continuity of provisions. This implies that the projects must contribute to the development of a situation in which the local structures can take over the care, counseling and support of survivors of man-made or natural violence.

    12     Wherever possible, and relevant, efforts must work towards achieving independence of local partners, in terms of expertise, financing and integration within the local care system. This requires the dissemination of expertise with respect to the quality of care, management, mutual consultation, co-operation, co-ordination, public relations and fund raising.

    13     The striving for independence of a local aid infrastructure should be expressed in specific and appropriately phased milestones and goals. These should be regularly evaluated, and if necessary adjusted, after each completed phase of the project.

    14     Every form of humanitarian aid struggles with the balance between striving for continuity of care and the available resources. Both the implementing organisations and the donor organisations should be aware of this issue during the planning and budgeting phase of the projects.

    15     The local partners should be kept informed as to the possibilities and limitations of the international efforts, and should be actively involved during the planning and phasing of the project.

    16     The international organisations are responsible for ensuring that the projects are not terminated ahead of schedule. If it can be reasonably foreseen that the available finances or personnel will not be sufficient to complete the project, the goals should be adapted to reflect the available resources.


    As said above, it seems like this document is carving out a long-term presence for Mental-Health projects in disaster-stricken area's. As I have observed, it is not unusual that organisations in this field use the presence of an armed conflict as a pretext for involving themselves in the community care. Once established it soon becomes clear that it is rather difficult, if not downright impossible to locate the 'traumatized' patients, since in each community the results of armed conflict show themselves in very different ways. Also, the population is not defining the consequences in terms of pathology, or even in terms of dysfunction. 
    The next step then is that these projects start to target the complete field of mental illnesses, and start to compete with the indigenous ways to handle symptoms that seem in western eyes comparable with schizophrenia, psychosis...( and the complete DSM IV), as well as epilepsy and mental retardation. It should be clear that these activities do not belong to emergency programmes, and should not be run by expatriates.

    Therefore, every program should be defined in terms of an exit strategy, or better even: the exit strategy should be the program. Longer lasting and/or structural aid should be received and handled by local organisations. Points 11 to 16 <=here concern, implicitly or more explicitly the problem of funding. Implementing organisations tend to bring their own funding, and tend to withdraw when their funding ends. This is, of course, at odds with their objective to establish permanent care. What is expressed here is a kind of dismissal of the responsibility for the fact that they introduce an activity that will not be sustained after their departure.

    Goals, Interventions and Methods

    General standard
    Psychosocial care should be aimed at strengthening or restoring the social (care) structures (empowerment) and on stimulating culturally suitable coping strategies and skills. Stress can be reduced and social stability enhanced by normalising daily life through the support of various social activities, education and recreation.
    Projects aimed at mental health care should, wherever possible, focus on the (re-) building or improvement of the regular care system. Dissemination of ‘suitable’ and ‘situation specific’ knowledge and skills is essential for achieving the stated aim of all aid projects: promoting self-sufficiency, independence, and sustainability.

    Specific guidelines
    17     The goals must be relevant, feasible, and phrased in a concrete manner. They should bear direct relevance to the stated interventions and any evaluation methods.

    18     Representative delegates of the target group(s) should be involved during the formulation of the goals and intervention strategies.

    19     Psychosocial care must not specifically focus on ‘curing’ posttraumatic psychopathology, but on the prevention thereof by means of promoting socially and culturally suitable bonds and activities.

    20     The methods, such as creative expression; grieving rituals; re-establishing daily routine; promoting self-help groups, income generating activities, (vocational) education and family reunion or stabilisation must strive to restore (social) self sufficiency and integration of the target group within the community at large.

    21     In principle, psychosocial and mental health care are offered to all individuals and groups of individuals within the target group. The care should be readily accessible and should work in a socially reinforcing manner; it should not be medicalisation and stigmatisation.

    22     Both the international and the local care providers involved in psychosocial projects should be able or be trained to identify those persons in need of more intensive or professional care. The co-operation with NGOs or local care institutions, which can provide the required special care, is essential.

    23     (Professional) groups such as teachers and religious leaders should not be trained as diagnosticians and psychotherapists. Instead they should be trained in counseling techniques and social skills, and be furnished with the knowledge to identify people with serious mental or behavioural problems so as to refer them for special care.

    24     Care should be taken to ensure optimal verbal and written communication with the target group. The quality of the translators and interpreters is key to this.

    25     The dissemination and mobilisation of knowledge and skills within the target group communities, together with psycho-education, serve to promote self-sufficiency, autonomy and continuity. These are to be preferred to direct care by international aid providers. The use of foreign personnel in aid projects should be limited as much as possible.

    26     Unless there are urgent reasons for deviating from this principle, psychosocial and mental health care should not be provided within the same project as material resources such as food, clothing, housing, income and the like. Care providers are strongly urged to play an active role in co-operating, co-ordinating and exchanging information with the organisations that provide these material resources.

    27     Psycho-education and information are crucial activities in any psychosocial or mental health care project. They serve to prevent unnecessary fears and uncertainties, and the stigmatisation of refugees, internally displaced persons and other survivors of violence. They also promote general awareness of the possible negative consequences of violent experiences and social disruption.

    28     Programmes that focus (in part) on conflict management, peace building, and on reconciliation are important in order to prevent further social and societal disintegration. This requires the development of insight into social-psychological, cultural, political and historical processes.

    29     The promotion of conflict management, peace building and reconciliation must not lead to a situation in which anger, hatred or fantasies of revenge are summarily dismissed or ignored. These reactions are understandable within the context of experiences of violence and repression, and should be treated accordingly. By having an opportunity to express and discuss these emotions, victims gain insight into and control over these feelings and fantasies. Without this, any true reconciliation or peace building is not possible.

    30     Psychosocial and mental health care for children and adolescents must concentrate on the reduction of stress factors and the re-establishment of a normal daily routine.

    • The care provided for children and young people must be relevant to their specific developmental phase.
    • When dealing with children and adolescents the parents, other caregivers and relevant authorities, such as teachers, should be kept informed and involved.
    • Education, (group) recreation and creative activities are vital.
    • Children should only be evacuated or placed in (foster)care if their safety is under threat.

    31     It is essential that organisations take measures to prevent burn out and secondary traumatisation of both local and foreign care providers.

    In this chapter <= these guidelines cross the line with some kind of manual. The guidelines have a wide diversity from very general to very practical and seem rather randomly gathered. Maybe this is a result from the 'draft' character of <= this document.

    Some comments :  guideline nr. 26, printed in red. In this article, the fact that all aid-projects that provide 'material resources such as food, clothing housing, income and the like' carry a strong mental health-component is completely overlooked. In the way that these resources are made available aspects such as 'aid-dependency', self-esteem, 'resiliency', have to be considered and are deeply influenced whether one wants or not. To say that intervention in the field of psychosocial and mental health care should not be provided at the same time is as saying that programmes on housing should be separated from social reconstruction. The fact that conventional programmes indeed are often implemented without any consideration for Mental Health aspects is the source of great problems.
    A division between these programmes however is again instrumental in reserving a special niche for mental health project.

    17. A guideline like this is completely tautological. It says that projects have to be effective in order to be effective.

    18. This guideline however is the opposite: Projects that are implemented after armed conflict are the result of western thinking about armed conflict and its implications. Guidelines like these are in fact already steps in de development of goals and strategies, as the title indicates. What should happen is the acknowledgment that most, if not all aspects of these projects are initially developed by initiators that have access to funding. Projects are also an expression of the ideological character of this funding. The next step should be that in an explicit exit-strategy, the project develops clear ideas how the initiators concede their positions as fast as possible to partners from within the target population, and how these partners can be prepared to handle the ideological character of the funding.

    Guideline 22 seems ad odds with nr. 21 and 23. Training local care providers to 'identify those persons in need of more intensive or professional care' is in fact turning a whole society into a diagnostic field. By turning the eye to the possible problem, one turns the eye into 'a pathologizing mode'. It happens often in our western society: after some kind of new pathology has been publicized in the popular press, suddenly half a population is diagnosed with the particular problem. Especially in situations where a complete population is feeling the effects of a disaster the question should be if individual pathology is/ can be/  relevant , and if so, who should be qualified to search for it. To think in terms of pathology like 'traumatized' about children for instance will lead most teachers on completely false ways while working in situations like after armed conflict. In these situations teachers are encouraged to define 'learning problems' in terms of problems with the children, in stead of as problems with the didactic climate, for instance.


    Political, Ethnic, Cultural and Religious Neutrality

    General standard
    It is an important and internationally accepted principle that medical and psychosocial support is offered regardless of a person’s political and religious convictions, sexual orientation or ethnic background. Aid projects should take into account that this principle may come under considerable pressure when put into practice. For example, both local and foreign personnel may experience problems when they are required to help and support (potential) perpetrators. The distinction between ‘victims’ and ‘perpetrators’ is not always clear. Furthermore, refugees or the community they live in, may be subject to political, religious or ethnic tensions. The principle of neutrality must not be used to ignore conflicts or to avoid discussing these issues, also with the target groups.

    Specific guidelines
    32     Having respect for the target group, their beliefs and cultural background does not mean that all local practices and beliefs need to be accepted and observed by aid organisations.

    33     It is foreseeable that, in some situations, the principle of neutrality will lead to ethical dilemmas or problems. These, then, need to be submitted to an ad hoc forum of experts.

    34     Those planning and implementing aid projects should be aware of the dependence and vulnerability of the target groups. The provision of aid may not be linked to the promotion of those particular political, cultural, sexual or religious convictions tied down to the aid organisation.

    35     Aid organisations must protect the target group from abuse by journalists. All media interviews with the target group must be conducted on the basis of informed consent.

    36     Although it is preferable to work together with local governments or authorities, it is not always possible or ethically responsible to do so. Where that is the case, aid organisations must take care not to provide governments or those in power with any information that could potentially be used against the target group, such as the location of refugees, the specific vulnerabilities, ethnic background or their political and religious persuasions.

    There is no such thing as Neutrality.

    We are used to see the philosophical, religious or political convictions of those that differ from us as 'ideology'. We rarely, however understand that likewise we too have our ideology, and that this too is not a 'neutral' agent. In fact, no human group can operate without ideology, because it is the ideology, that is permeated in all aspects of our knowing and acting, in our language and in our beliefs, that permits us to act and reflect upon our actions.

    Especially in the case of intervention in another belief-structure, and this in a period of distress too, there is no situation thinkable in which we can be considered 'neutral'. We, as the acting agents that are 'helpers' and at the same time carriers of funding, always have to be questioned ethically; before, during, and after the intervention. 

    There can be no intervention project, therefore, that does not permanently assesses its own ideological points of departure, and brings this assessment also to the core of the relationship with the clients in the form of a permanent discussion in a form that is acceptable to the clients.

    A good example is the problem of western helpers regarding 'innocence' or 'guilt', or as it is stated here, 'victims' or 'perpetrators'. As seen above, in our ideology, victims must by definition be innocent, and we see ourselves (and present ourselves) as the helpers of 'innocent victims'. In situations of armed conflict in communities, these distinctions are highly questionable, and definitions of guilt and innocence are closely connected to the terminology of specific groups in a conflict, or may even be even absent. In many cases, the west is introducing the concept of innocence and therewith creates a new element in the self-image of the people involved. Therefore the west should discuss how to eliminate these concepts where necessary.

    Transcultural aid should have as a rule of thumb that all aid is given within the ideological framework of the receptant, and make explicit those field where the ideological framework of the receptant is not accepted by the donor in a separate document on forehand. This document should always be available to all people that ask for information on a project, and be translated in the language of the receptants with help of local philosophers (= which means: not translated by the 'technical translators' that are usually made available to the NGO-community). This document should also be updated constantly.

    A special mention should be for point 35. 
    All to often, aid-workers seem to regard the community that they help as 'owned' by them. In many cases these workers tend to feel that the press needs their permission to talk with people in their domain. This is dangerous. We may agree that the media very often commit terrible acts in order to get their stories, but still they belong to the world of the people that we try to help, and it is not our place to intervene or control the contacts between the media and the population. It is the right of everybody to talk to everybody.
    Another matter is, of course, the question if we are obliged to bring any reporter to our 'most pitiful client'. Very often, it is the aid-workers that compete for attention of the press, directing attention to catastrophic images, or even sending them out with their own logo well visible in the corner.


    Project Evaluation

    General standard
    Adequate project evaluation is essential. In the interest of the development of know-how concerning the design and effectiveness of psychosocial and mental health care projects, the programme or project evaluation must be given due attention in the planning and budgeting. The evaluation may address the organizational aspects of the project as well as the implementation or the effects of the interventions.

    Specific guidelines
    37     Local partners should be actively involved in the design, implementation and formulation of the evaluation.

    38     The evaluation methods should bear direct relevance to the specific and operationalised goals. Where pertinent, the negative effects of a project or programme should also be investigated.

    39     The evaluation methods and instruments must be able to realistically assess the processes and outcomes of the interventions.

    40     In terms of design, implementation and reporting, the evaluation study should follow the same guidelines as those for scientific research (see below).

    41     Preferably, the evaluation of the results of interventions should be carried out by independent experts.

    42     The evaluation must be cost effective and proportional, in terms of scope and methods, to the project or programme to be evaluated.

    43     The evaluation report or any summary thereof should be thorough and reliable, and be made available to donors, to partners and to relevant third parties.

    44     If the evaluation method requires research amongst the target group, the group should be made aware of this well in advance and if necessary, after-care should be provided.

    Evaluation is a step in a cycle. Every intervention project should be permanently evaluating the development of the project . To evaluate means, in many cases, an explicit observations of the difference in frames that helpers and clients have. Clients may very well differ in their evaluation of results, especially if the helper has objectives that are wider than that of individual clients, or special groups of clients. Evaluation is therefore a rather complicated process in itself, a fact that is made more difficult because the field of professional mental health workers in these situations has offered no accepted criteria for 'results'.

    In <= these guidelines evaluation is mainly seen as an overall process, to be set up before a project, and to be implemented after the project. To set up a system of evaluation, actively involving local partners (<=37), is however usually impossible in projects after armed conflict.  One is very happy to slowly involve local partners in the process of the project, but to expect that partners could really be involved in such a process before the projects starts, is to say in fact that they would be perfectly able to manage the project themselves. In this case, outside organisers should not be necessary.

    Even such an overall 'evaluation' can not be set up like scientific research, for the simple fact that the objective of intervention is subjective. This means that the project interferes with reality on the base of permanent observation and evaluation, and as a result, develops shifts in objectives, concepts and the interpretation of facts. These shifts are not compatible with scientific - distanced- observation, reason why exactly these shifts are forbidden in the scientific paradigm.
    On top of this, the observed population is being aware (should be aware) of being observed, and this observation and the resulting influence mean in fact re-iteration: which tends to make the process chaotic .


    Scientific Research

    General standard
    Scientific research into the field of psychosocial or mental health care is by no means a necessary part of projects. If research is done – either in combination with aid or not – it must be aimed at the improvement of insights into the condition and needs of the target group, and directly or indirectly benefit the respondents or the quality of (future) care.

    Note: Scientific research refers to research that falls outside the scope of the preparation and evaluation of projects.

    Specific guidelines
    45     Scientific research that is restricted to the collection of data about the nature and prevalence of psychopathology may only be carried out if there are convincing reasons to believe that this knowledge will be relevant to the development of policies and to the design of aid programmes.

    46     Research must be carried out and supervised by sufficiently qualified and experienced researchers. The study must be designed, implemented and reported in accordance with appropriate current standards for responsible and qualified research.

    47     The design and protocol of the study must be submitted to an expert (medical) ethical committee for evaluation, preferably also one from the country in which the research will be carried out.

    48     Participation in the research projects should be on the basis of informed consent. Potential respondents must be provided with adequate and complete information on which to base their decision. Where possible this information should be provided in written form and in a ‘language’ that is readily understood.

    49     For research involving children below the age of 12 years, the information and the decision as to whether or not to participate goes to the child’s parents or caregivers.

    50     The offer to provide care must not be contingent upon the decision by the target group as to whether or not to participate in the research.

    51     If the research is likely to place an emotional or practical burden on the respondents, they should be provided with adequate counselling and after-care. It may be necessary to exclude the participation of particularly vulnerable individuals.

    52     The research results must be made public through the appropriate scientific or policy forums. They must be made available to the donors of the research and - if so agreed - to the participants.

    53     Any research data that are subject to potential misuse must not be made available to those institutions that are capable of using the information against the participants or their communities. A request for research by such an institution must be denied on ethical grounds.

    Scientific Research and Intervention projects can not be combined.

    The main reason for this is that both actions have paradigmata that are too far apart, and, partially, contradict each other.
    Science has long-term goals, that are not connected to the specifics of the subject that is being studied, or even, in fact, is as much distanced from these specifics as possible. 
    Intervention projects have short- or middle term goals that are completely resultant from the specifics of that actor and the supported community.
    In the field of mental health after armed conflict science has, moreover, a track-record of disagreement on many levels. From techniques like debriefing to the very concept of Trauma, the field is deeply divided, and seemingly unable or even unwilling to agree on a platform of discussion where all parties are involved. Yet, different scientific schools translate their beliefs into projects where implementation of intervention is often used as an entry in the field to do more research.
    In these projects, funding for research and intervention are mixed, and in many cases intervention is influenced by the need of gathering of 'scientific data'.
    A population in distress will never be able to give whatever form of consent to the gathering of these data, let alone 'informed' consent. On top of that many cultures are so strange to the essence of western scientific assumptions like 'critical distance' that the very concept of research can not be translated correctly in to local philosophic concepts.

    Of course there should be an obligation for everybody setting up intervention projects, to analyse and integrate all results of scientific research and evaluation. Here again, the scientific community is making this impossible. There is no place where the full body of scientific results is available in a form that a) has the approval of the scientific community, and b) is readable for intervention professionals. Instead, literature is scattered in all kind of places, and authors ignore too often the results of competing scientific models. There is no authority that forces scientists to integrate each other's results, or to collectively abandon results that did not prove correct.
    This is by no means a problem that is specific for this field, yet in this field the consequences are highly problematic.

    On the other hand, intervention projects should be open and co-operative for scientific research, as long as this research does not corrupt the intervention. Scientific projects should have their own funding, and use their own infra-structure.
    The problem of 'informed consent' should not be underestimated, since in many cases this is a hollow sentence. 
    Scientists often give incentives to respondents, and this practice should be openly discussed.