A Call to Action: Implementing best practices to support adolescent mental health in Lebanon by strengthening families and communities

Prior to the devastating Beirut port explosion, economic crisis, and the COVID-19 pandemic, the prevalence of anxiety and depression within adolescent populations in Lebanon was already higher than the global average [3]. The additional stressors families have faced over the last 18 months are likely to have exacerbated this distress, with over half of households in Lebanon and two thirds of refugee households, living under the poverty line. The crippling impact of the devaluation of the Lebanese pound (lira), hyperinflation and high unemployment mixed with political paralysis and fears of sectarian and regional conflicts, are likely to take their toll on the mental health of the population. We outline three best practices from the field of global mental health to ensure the most effective mental health programming to meet the substantial needs of children and their parents in Lebanon today, and in the future. 

Best Practice 1: Take a stepped care, public health approach.

In the context of this increased burden of psychological distress and mental health needs, the treatment gap in Lebanon is as high as 90%, with major barriers linked to the predominantly private health care system for which the majority of low-income families have no access. COVID-19 related lockdowns have further impacted the availability of mental health services, particularly for the most vulnerable without access to internet. The international Inter-Agency Standing Committee (IASC) guidelines for mental health and psychosocial support (MHPSS) [4] in emergencies recommends a stepped care coordinated approach that builds upon existing resources and trains non-specialist facilitators as a strategy to close this gap. A stepped care approach includes community-based prevention and promotion programs that reduce the need for specialized care in low resource settings. 

Best Practice 2: Take an integrated, multi-sectoral approach.

Children and families in Lebanon are experiencing numerous social determinants of poor mental health, often compounding and exacerbating over time. These include: lack of safe spaces to play, loss of livelihoods, lack of basic needs and adequate shelter, and increases in violence in the home and community.  The IASC also recommends that in complex crises such as this, mental health prevention and promotion activities should be integrated into other sectors such as Food and Security, Shelter, or Protection, to simultaneously reduce risk factors and promote wellbeing. One example of this comes from Sierra Leone, where an MHPSS program – the Youth Readiness Intervention – has been integrated into a Youth Employment Promotion Programme [5]. While access to livelihoods is expected to improve mental health and wellbeing, similarly improved psychosocial skills can improve engagement and benefit from such opportunities. 

Best Practice 3: Consider the social-ecology of the child.

Research on child and adolescent mental health in humanitarian, low resource and conflict-affected settings has consistently found that family functioning, social support, and community cohesion serve a protective effect, buffering the impact of high adversity on child and adolescent mental health [6]. In practice, mental health and psychosocial support interventions aiming to promote mental health and prevent or treat mental disorders in child populations living in humanitarian settings have tended to focus on individual children, addressing emotional regulation, coping mechanisms, and other internal processes. Whilst these interventions have growing evidence of effectiveness [7], they have historically neglected systemic protective factors like family and community. In contexts of collective distress such as in Lebanon, this focus has been heavily criticized for lacking contextual and cultural relevance[8]. It also reflects the limitations of individual and specialized care in addressing collective distress and reducing the treatment gap. A review of family interventions in low and middle-income countries found good evidence for their effectiveness on child and adolescent mental health. Programs tended to primarily focus on parenting and caregiver coping, and very few programs took a comprehensive approach to the family system as a whole. Additionally, no evaluated family interventions were found in Lebanon nor in neighboring countries, and few programs focused on at-risk adolescents[9]..

In response to this gap and these known best practices, we are embarking on a new study (funded by AHRC-FDCO) to develop and test a contextually and culturally sensitive family systemic module that can be delivered alongside the existing United Nations Children’s Fund (UNICEF) Focused-Psychosocial Support (FPSS) program for at-risk adolescents in Lebanon [10]. The intervention is delivered by non-specialists for families identified through the child protection system as needing more support, and aims to improve family functioning, which is predicted to lead to improved child and parental mental health and wellbeing. This shift of focus from individual to family aims to contribute to more systemic and contextually relevant interventions that can help support adolescent mental health in Lebanon at a time when the country is grappling to cope with the impact of multi-level emergencies. 

Given the pervasive uncertainty and crises facing the population in Lebanon, shifting focus to more stepped-care, systemic interventions that address the wider social ecology of young people and consider social determinants of mental health and wellbeing, is likely to be more effective in promoting mental health and mitigating the harm of the many adversities families face in Lebanon. In order to surmount the current challenges, it is vital for mental health and wellbeing considerations to be integrated across all sectors and responses.

Acknowledgements: We would like to acknowledge our study team: Zahraa Shaito, Anas Mayya and Sally Farah at the American University of Beirut, Professor Mark Jordans at War Child Holland, Professor Theresa Betancourt at Boston College of Social Work, Professor Michael Donnelly at Queen’s University Belfast, Professor Alan Carr at the University College Dublin and Maliki Ghossainy at the Wheelock College of Education and Human Development, Boston University; and our implementing and technical support partners Roula Abi Saad at UNICEF Lebanon, Diana Abou Naccoul  and Ahmad Einein at Terre des Hommes Italia, Bryony Walsh and Sarah Chreif at the Danish Refugee Council, Joseph Elias and Bassel Meksassi at War Child Holland, Hady Naal at the Global Health Institute, Rabih el Chammay at the National Mental Health Program, and all members of our Community Advisory Board. 

This work was supported by the AHRC-FDCO Collaborative Humanitarian Protection Research program (grant number 103916).

Filters:Mental Health, Family Health, Community Health, Lebanon

Contributors

[1]: Tania Bosqui, Assistant Professor, Department of Psychology, American University of Beirut

[2]: Felicity Brown, Senior Researcher, War Child Lebanon

References 

[3]: Maalouf, F. T., Ghandour, L. A., Halabi, F., Zeinoun, P., Shehab, A. A. & Tavitian, L. (2016). Psychiatric disorders among adolescents from Lebanon: Prevalence, correlates, and treatment gap. Soc Psychiatry Psychiatr Epidemiol, 51(8): 1105-16.

[4]: IASC. (2007). IASC guidelines on Mental Health and Psychosocial Support in Emergency Settings. Geneva: World Health Organization Inter-Agency Standing Committee.

[5]: Betancourt, T. S. (2018). Youth FORWARD: scaling up an evidence-based mental health intervention in Sierra Leone. Available from https://odihpn.org/magazine/youth-forward-scaling-up-an-evidence-based-mental-health-intervention-in-sierra-leone/ (accessed 17 February 2021).

[6]: Betancourt, T. S. & Khan, K. T. (2008). The mental health of children affected by armed conflict: protective processes and pathways to resilience. International Review of Psychiatry, 20(3): 317–328.

[7]: Brown, F. L., de Graaff, A. M., Annan, J. & Betancourt, T. S. (2017). Annual Research Review: Breaking cycles of violence – a systematic review and common practice elements analysis of psychosocial interventions for children and youth affected by armed conflict. J Child Psychol Psychiatry, 58(4): 507-524.

[8]: Bosqui, T. (2020). The need to shift to a contextualized and collective mental health paradigm: Learning from crisis-hit Lebanon. Global Mental Health, 7: E26.

[9] : Pedersen, G.A., Smallegange, E., Coetzee, A. Hartog, K., Turner, J., Jordans M. J. D. & Brown, F. L. (2019). A systematic review of the evidence for family and parenting interventions in low- and middle-income countries: Child and youth mental health outcomes. J Child Fam Stud, 28: 2036–2055.

[10] :Brown, F. L. & Bosqui, T. (2021). Family focused psychosocial support for at-risk adolescents in Lebanon. Available from https://www.researchgate.net/project/Family-focused-psychosocial-support-for-at-risk-adolescents-in-Lebanon (accessed 17 February 2021).