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Table of Contents
COMMENTARY
Year : 2021  |  Volume : 19  |  Issue : 2  |  Page : 149-154

Mental Health Interventions in Complex Political Contexts


Graduate School of Psychology and Counseling, Cambridge College, Boston, MA, USA

Date of Submission17-Apr-2021
Date of Decision22-May-2021
Date of Acceptance03-Jun-2021
Date of Web Publication09-Sep-2021

Correspondence Address:
PhD Elena Cherepanov
Graduate School of Psychology and Counseling, Cambridge College, Boston, MA
USA
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/intv.intv_14_21

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  Abstract 


Global mental health specialists provide mental health (MH) services worldwide in various settings with complex humanitarian needs. Tailoring MH interventions and psychosocial support to the context and culture is essential for ensuring safe and competent services. A complex political context (CPC) is characterised by complex political dynamics, social instability and political violence resulting in gross violation of human rights and massive trauma. Examples of such settings include dictatorships, military junta and other forms of government-sponsored, sectarian or ethnic violence towards marginalised groups who are targeted, oppressed and discriminated. In some countries, receiving MH services can expose beneficiaries and put them at risk. Scaling up MH support is needed when serving persons with special needs and those at particular risk for discrimination and victimisation. The coronavirus disease 2019 (COVID-19) pandemic has worsened the situation and been used by unscrupulous politicians to tighten governmental control, blame already marginalised groups and deny or further limit their access to resources and health care. These guidelines aim to equip MH workers with an understanding of the professional challenges and ethical dilemmas posed by CPCs. They offer recommendations for programming and delivering MH services in CPC. Providing MH interventions in a CPC calls for special professional expertise, extensive use of supervision and peer support, and personal competencies such as self-awareness and self-care.

Keywords: complex political context, ethical dilemmas, global mental health, mental health services, political violence, refugees


How to cite this article:
Cherepanov E. Mental Health Interventions in Complex Political Contexts. Intervention 2021;19:149-54

How to cite this URL:
Cherepanov E. Mental Health Interventions in Complex Political Contexts. Intervention [serial online] 2021 [cited 2021 Dec 2];19:149-54. Available from: https://www.interventionjournal.org/text.asp?2021/19/2/149/325799




  Introduction Top


“Fear, disgust, resentment − long-term experience of the same emotions. Nothing happens, you sit on the doorstep and think: what to do? what to do?.. You can’t do anything. Everything is controlled, all mobile operators. You are like under a magnifying glass. I feel very bad. A person should not have such feelings. This is the feeling of the triumph of evil − and there is nothing you can do” (Burtin, 2021).

The increased polarization and politicisation of the global context is recognised in the rise of authoritarian and nationalistic tendencies and intensified political, secteraian and ethnic violence. With this article, I want to discuss the role of mental health (MH) services in complex political contexts (CPCs), which create enormous MH needs and so the barriers to meeting them. When it is difficult to predict the outcomes, any intervention may heighten risks for both beneficiaries and providers. Do we need to get involved at all? How to avoid getting caught up in impossible dilemmas and make the situation worse instead of helping? What can be the goals of MH services in CPC? And what expertise and competencies may be required to conduct safe and effective interventions and strengthen individual and community resilience?

The operational guidance for emergency settings issued by the Inter-Agency Standing Committee (IASC) encourages cultural sensitivity, contextual relevance and situational appropriateness in conducting mental health (MH) and psychosocial supports (IASC, 2007). They urge that interventions be tailored to the issue or settings. These guidelines draw upon the author’s experience in providing direct care in complex humanitarian emergencies and complex political contexts (CPCs), training local specialists and consulting international nongovernmental organisations (INGOs), and researching the psychological legacy of authoritarian and totalitarian regimes (Cherepanov, 2020b). Although every CPC is unique, many recommendations are context-specific and carry cross-cultural relevance.

A CPC is a setting affected by complex political dynamics, social instability, political or sectarian violence and ethnic cleansing resulting in gross violation of human rights and massive trauma. The full extent of the impact of CPCs is yet to be recognised. The literature on the implications of CPCs has only recently started to emerge, fuelled by interest in the psychological aftermath of societal victimisation and the governmental abuse of power.

CPCs can be recognised in both low and high resource settings and any place where belonging to a particular political, religious, tribal, ethnic or gender identity group or expressing political convictions makes a person a target of violence, institutional discrimination and systematic persecution. Examples include (but are not limited to) countries with the ongoing or recent history of dictatorship, the military junta, political, sectarian and ethnic violence, such as some post-Soviet regions, China, Cambodia, Vietnam, Congo, Iraq, Iran, Venezuela, Myanmar, and Afghanistan. Unfortunately, the number of such countries is growing.

Politically motivated violence distinguishes a CPC from other settings with high violence rates. Conteh-Morgan (2003) defined political violence as violence perpetrated by a government administration to achieve political goals or force opposition into obedience. Nonaction on the part of a government, such as refusing to alleviate famine or otherwise denying resources to politically identifiable groups within their territory, can also be characterised as a form of political violence. For example, the coronavirus disease 2019 (COVID-19) pandemic has been used by unscrupulous politicians to tighten governmental control, blame already marginalised groups and further limit their access to resources and healthcare.

Dictators and totalitarian leaders seek to impose total control over their citizens’ lives and often use secret police and informants to identify those who disobey. To coerce into obedience and control behaviour, the ruling party may resort to using fearmongering, intimidation, political violence, and torture. They try to suppress independent opinions and threaten imprisonment for anyone who disagrees. Such leaders can try to recruit MH providers to report disloyalty or use punitive psychiatry to punish dissidents, which was a common practice in the former Soviet Union (Bloch & Reddaway, 1977) and in Somalia in the 1970s, where psychologists were employed to identify those who were disloyal to the government (Cherepanov, personal communication, 20 March 2016).

An administration can take private property away at any time, deliberately foster divisiveness and inflame racial and ethnic tensions by designating a “public enemy” and portraying them as conspiring to undermine the nation’s progress. Indoctrinated perpetrators may use political or religious beliefs to justify state-sponsored violence against a minority or marginalised group by claiming it is for the nation’s “greater good” while blaming the victims for “inviting it”. Informational and economic isolation from the rest of the world becomes a breeding ground for conspiracy theories.

Due to the subject’s sensitive nature, this article mainly uses generic case examples that are loosely rooted in actual circumstances.

Psychological Impact of CPCs: “Don’t Trust, Don’t Show Your Fears and Don’t Ask for Help”

Living in a CPC profoundly impacts MH, wellbeing and alters how people relate to self, other people and the world. CPCs not only affect victims but also erode the psyches of perpetrators and bystanders.

Some cope with the chronic fear, anxiety, depression and unpredictability via social and emotional withdrawal; or resort to drinking alcohol and other forms of self-deructiveness. Others may choose to keep a low profile, trying to avoid any exposure or unwanted attention from the authorities by any means. Social cognitions that develop as adaptive in response to uncertainty and hostility can reflect powerlessness, social fatalism, apathy and learned helplessness which translate into distrust of governmental officials, administrators and outsiders, including MH providers.

Sustained trauma is often complex and chronic and stems from cumulated hardship, multiple and ambiguous losses (e.g. missing, imprisoned or injured friends or family members), and lacking access to health care. Many become victims or witness violence; some are tortured or know those who were. Trauma in CPCs increases individual vulnerability and social isolation, especially in those with previous trauma. These individuals can be disproportionally affected by famine or pandemic because of their lack of access to resources. Profound distrust, fear and shame associated with CPC often prevent traumatic experiences from aggregating, which means the emergence of a shared trauma experience by which survivors can relate and validate each other’s experiences or reach out for help. Lack of aggregation affects the community’s ability to develop mutual support systems (Cherepanov, 2020b).

“Don’t trust, don’t show fear, don’t ask for help” are the survival instructions once formulated by and for the prisoners of labour camps during Stalin’s regime (Cherepanov, 2015, 2020b). They have also been recognised by survivors and their descendents coming from other countries affected by CPCs. What do these instructions really mean?

“Don’t trust”. In a CPC, no one, even friends or family, can be trusted because they may be informants.

“Don’t show your fear”. It is not safe to disclose any personal weaknesses because it renders one easier to be taken advantage of.

“Don’t ask for help”. Reaching out and accepting help can reveal vulnerabilities that adversaries can exploit. A person who receives help may be asked to return the favour on the unsympathetic grantor’s conditions.

These social beliefs reflect societal dysfunction, powerlessness and social fears and are credited with shaping social behaviour and attitudes. They affect trauma-coping and help-seeking behaviour and complicate access to health and MH services.

Barriers to Accessing MH Services

In addition to issues of language, cultural barriers and stigmatisation of MH common to most multicultural settings, accessing MH services in CPC is associated with additional obstacles. For example, logistical barriers such as information about available services may be difficult to share or obtain. In some regions, authorities can install artificial barriers to learning about available MH services. The administration can deny INGOs’ permission to operate in a particular area or make this permission contingent upon sharing information.

Follow-ups or referrals may not be available or recognised by a government-managed public health system, especially when an NGO is partially or fully funded and run by foreign actors. Siege mentality is “a collective state of mind in which a group of people believes themselves constantly attacked, oppressed, or isolated in the face of the negative intentions of the rest of the world” (Christie, 2011, p. 997). In this spirit, the government administration can accuse foreign-based international INGOs of conspiring against the public interests and portray them as a foreign entity with ulterior motives who want to hinder “the nation’s progress”.

Service recipients or the community may internalise this attitude and become cautious and distrustful of MH providers. It also may be unsafe to associate with foreigners, even in the form of receiving humanitarian assistance. For example, in one instance, MH providers were accused of “spying” because they were “asking too many questions” (Cherepanov, personal conversation, 2012). Luckily, they were not arrested, but they had to close the project prematurely.

Goals of Interventions

In CPCs, MH interventions prioritise mitigating societal stressors, strengthening resilience and preventing cycles of violence and revictimisation. When MH and physical health conditions or exposure to severe trauma compound social vulnerabilities, marginalised members (i.e. belonging to a particular tribal, ethnic, religious or sexual minority) are often excluded and discriminated against even within their community (Cherepanov, 2008, (2016)). The goals of interventions can be achieved by:
  • Supporting victims or witnesses of violence and torture and those who have experienced traumatic loss (murder, suicide or missing family members);
  • Supporting marginalised and vulnerable groups and individuals with special needs: persons who have disability or MH issues, victims of sexual gender-based violence (Cherepanov, 2019b) and others;
  • Mobilising community resources and mutual supports;
  • Psychoeducation and destigmatisation;
  • Correcting misinformation;
  • Achieving systemic impact by training and supporting local providers.


Ground Principles of Mental Health Programming

Do No Harm

In CPCs, any MH intervention must be evaluated from a contextual relevance and harm reduction point of view (Wessells, 2009). For example, indiscriminative empowerment can result in unsafe behaviour, and relaxation can result in people lowering their guard in a hostile environment, increasing their personal risk. Potential harm from the exposure can also be a concern when advocating for clients or taking their photos.

Safety is Always a Priority

In a CPC, concerns for both the beneficiaries’ and providers’ safety are an undisputed priority. Although MH providers do their best to preserve confidentiality, a person can attract unwanted attention just by being helped. To manage these risks, providers must discuss the limits of confidentiality and safety planning with clients on a routine basis and must always be aware of their own security and whether they are being followed.

Confidentiality Cannot be Guaranteed

Assuring confidentiality can be especially challenging in a CPC: authorities can go a long way to seek access to sensitive information using various means, such as searching offices, installing listening devices or even using staff and interpreters as informants. Records and electronic devices can be searched, misused and confiscated.

All Medical and MH Services Must be Trauma Informed

Any provision of health services must be based on the assumption that clients have been traumatised and may not have a place of safety. When working on a single exposure to trauma, it is essential to keep in mind that it may be a part of an extensive, chronic and cumulative traumatic experience.

Affiliation is Important

Any MH programming must involve special measures to strengthen protections for the beneficiaries and providers as well as provisions for preserving health record confidentiality, emergency communication and security protocols, and plans for programme termination. Working with an established NGO offers such an additional layer of protection, administrative support and quality assurance.

Partnering with local NGOs and local or national administration like public health systems has many benefits: it allows partners to take advantage of established infrastructures and resources. It also improves access to beneficiaries. In this case, the role and degree of independence of the MH provider and the provisions related to impartiality and neutrality must be carefully weighed and negotiated ahead of time to avoid political entanglement when aid provision is used for propaganda purposes.

Local Providers must Lead MH Services

Local providers, whenever possible, are expected to take the lead in coordinating relief efforts because they are intrinsically familiar with the current situation and local culture. They are invested in the future of their country and will remain there after external providers exit. International experts’ involvement is mainly concerned with developing local MH support systems, psychoeducation, training and supporting local MH workers. It is recommended that outsiders provide a higher level of care (i.e. individual counselling and psychotherapy) only when there is a critical need and there are no local resources available. Compared with psychological first aid (PFA) and crisis support, these methods require longer engagement, follow-up and aftercare support, which may not be available.

Choosing Small Interventions which Can Lead to Big Changes

Strategically chosen small interventions with the potential for creating a systemic impact (e.g. psychoeducation) seem preferable over grandiose and bold projects aiming at cardinally transforming community life. It is rarely a good idea in global mental health (GMH) in general. Still, it can also become dangerous in CPC, where it is difficult to account for all the consequences of any helping intervention.

Consideration for Safe and Competent MH Interventions

Tailoring MH interventions to the specific CPC is essential for providing safe and competent services. Here are some considerations for MH providers:
  • When reaching out for help is associated with exposed vulnerabilities, then outreach, education and partnering with primary care and community-based organisations may be needed to engage MH service beneficiaries.
  • Establishing a physical or mental place of safety is a crucial component of any trauma work. This means that a person must feel safe and comfortable before addressing trauma. When providers assist people with temporarily feeling safe (e.g. use of meditation, relaxation through guided imagery), helping a person with switching back to alertness and vigilance before the end of the session would allow for readjustment to a hostile environment.
  • When the future seems unpredictable, exploring available choices, even when these choices are limited, helps with regaining a sense of mastery of one’s own life. Focus on the here-and-now and the immediate future restores a sense of having control even if this control does not extend beyond several hours or the end of the day.
  • Besides individual sources of resilience in CPCs, studies have demonstrated that fostering trustful and supportive relationships in the family helps one to become more resilient, better cope and resist indoctrination and brainwashing (Cherepanov, 2020b).
  • It may be beneficial to discuss with clients whom they can trust, and what they tell their family members about receiving MH services.
  • Providing positive feedback about the efforts to navigate the situation while emphasising resilience helps to recognise and acknowledge the ongoing struggle.
  • Every session must be conducted as if it were the last one and include psychoeducation on self-help solutions and coping skills to be used independently.


Don’ts

  • Do not ask too many questions. Excessive questioning can remind individuals of an interrogation. Focus on treatment-relevant information instead.
  • Do not ask for trust. In most interventions, trust is not required. It will or will not come in the process of building rapport.
  • Do not try “to get to the truth”. Honesty has never been a qualifying characteristic for receiving MH support.
  • Do not ask for or insist on disclosures. Ask the client to volunteer the information that may be important for a provider to know instead.
  • Do not encourage or discourage participation in protests against the government. Assist the client with exploring the pros and cons (risks) of such a decision instead.
  • Do not create electronic lists of clients with identifiable information as the records can be hacked. Instead, try to minimise the use of electronic record-keeping or do it with identifier removed. Technology can be a potent tool in addressing MH concerns. It can also be used to monitor people.


Interventions

Work in CPCs places a specific limitation on the choice of interventions. For example, there was an instance where the administration deemed yoga and other holistic approaches as competing with the ruling party’s ideological and religious agenda. As a result, these training groups were banned, and the leaders were fined and threatened with arrest if they continued.

What do providers need to consider when determining appropriate MH interventions in a CPC? Distrust of MH providers may question the effectiveness of commonly used psychological interventions for trauma, especially talk-based methods (e.g. cognitive-behavioural or group therapy). Working with symbols and metaphors (e.g. expressive arts, play therapies, body-oriented approaches) does not require personal disclosure and allows a person to express symbolically what may be difficult or unsafe to express with words. The World Health Organization, War Trauma Foundation and World Vision International (2011) recommend PFA for use in conflict-affected areas. This approach emphasises recognising and fostering personal resources, strength and resilience and linking to support systems. PFA also offers practical tools to cope with anxiety, depression, social isolation and sleep problems, which can be used as self-help modules outside of the sessions.

GMH practice has demonstrated the advantages of integrated primary care services, preferably over a single-services mode. Often, psychological distress presents with somatic symptoms, and the primary care provider is often the first to identify these as psychological needs. Integrated care allows tackling medical and MH problems concurrently, especially when working with victims of violence. Also, seeking medical care appears less stigmatised than reaching out for MH services.

Psychoeducation also helps to normalise trauma reactions and contest stigma. It teaches about coping, sources of strength, resilience and fosters mutual support.

Additional Considerations

Perpetrators also may need MH services. In CPCs, the line between perpetrator and victim can be blurry: a perpetrator can become a victim in the next cycle of political violence. It is important that MH providers recognise that perpetrators are often also victimised, and that addressing trauma may open an opportunity to break the cycle of violence.

Importance of self-awareness in service providers. Working with CPCs can be particularly psychologically challenging for MH providers. They need to remain acutely aware of their safety, countertransference, boundaries, biases and fantasies and regularly seek supervision and peer support (Cherepanov, 2020a).

Training Local Providers

Professional connection is often an efficient way to establishing professional collaborations for training, supervising and supporting local MH providers. It is an essential step towards facilitating dialogue and developing peer support systems. The core competencies in training can include the components of PFA (World Health Organization, War Trauma Foundation & World Vision International, 2011) and tools for psychological recovery (Berkowitz et al., 2010), which contain clear, practical and portable recommendations for managing trauma symptoms, depression, anxiety and sleep, and also self-care.

PFA training can be offered to key community actors who can become champions of change by sharing the learned information with the community. For instance, PFA skills can be effectively used by healthcare personnel, community and faith leaders, social and outreach workers, teachers and other human service providers who have direct access to traumatised population.

It is important to consider that some local providers may have been traumatised themselves, and self-awareness and self-care must be included in the training. This training should include recognising and managing countertransference and fantasies, understanding the safety imperative and burnout prevention (Cherepanov, 2018, 2019a).

Refugees Arriving from Countries Affected by CPCs: What MH Providers Need to Know

Refugees fleeing regions affected by CPCs carry with them to their places of resettlement related social assumptions about the self and others. The CPC experience tends to produce severe societal trauma and fundamental distrust towards administration, health authorities and other community members; such mutual distrust can complicate community integration.

Even when MH services and psychosocial supports are available, distrust can hinder accessing them. The immigration process is not conducive to health-related self-disclosures. Having MH issues may be used as an excuse (or perceived as such) to deny permanent residency. Such distrust increases refugees’ risk of revictimisation and being taken advantage of as it prevents them from seeking help and reporting, for example, domestic violence or other crimes to law enforcement (Cherepanov, 2008).

Stresses of resettlement can exacerbate the community’s internal negative dynamics and lead to further social exclusion of already marginalised groups. Many refugees are also acutely aware of the possibility that there may be former perpetrators in the community who may threaten their family members in their country of origin. Some may have good reasons to be afraid of being recognised and may go a long way to prevent this from happening.

All this means that when the refugee’s community is unwilling or unable to support its members, MH providers may need to scale up their support and facilitate the larger community engagement outside of the ethnic community.

Ethics

Work in CTC exposes MH providers to unique ethical dilemmas.

Advocacy Versus Do No Harm

Advocacy is an essential component of GMH work, and balancing it with the “Do No Harm” principle at times presents a daunting task. “If I speak up against the government’s actions or voice public support for my clients, in the best-case scenario, I will not be able to continue my work. In the worst case, they will be punished. If I don’t say anything—I betray myself”. This dilemma is described in the film, ‘Mr. Jones’, (Holland, 2019), which depicts an ambitious young journalist, Gareth Jones, who in 1933 travels to Soviet Union where he discovers the evidence of the Holodomor. This artificially created famine resulted in mass starvation and death in Ukraine. On his return to Britain, he faces a dilemma: Stalin’s administration took several British engineers hostage and threatened to execute them if Jones shares what he witnessed. Jones’ decision was based on simple maths: hundreds of thousands of people dying of starvation versus the lives of several engineers. He goes public and the engineers are released under international pressure. In real life, these dilemmas may not be as obvious and do not always end this well.

There may be occasions when providers are compelled to stand by their beliefs and against blatant human rights violations and bear witness to mobilise international support for the victims. But providers also need to be aware that engagement in such public activity can expose their beneficiaries in such a way as to make future assistance impossible, and thus need to take reasonable measures to minimise such risks.

Neutrality and Impartiality Versus Professional and Moral Values

Commitment to humanitarian principles of neutrality and impartiality in CPCs sometimes conflicts with the core professional and moral values of the MH profession which require us not to engage in political controversies. This dilemma poses the question of whether a provider shall equally assist the perpetrators or should remain neutral and impartial when faced with a blatant human rights violation. Here are examples of similar dilemmas:
  • The administration places conditions on granting access to beneficiaries. Such conditions may be monetary (receiving payment for the permission), sharing sensitive information with the government or requiring assistance to police and government officials concurrently.
  • A dissident or political activist may ask an international provider to secretly meet with them to share information about the violation of human rights.
  • A health provider is offered access to inspect secret detention facilities but asked to sign a non disclosure agreement.
  • A resident who is at risk of persecution asks an MH provider to assist with seeking asylum.


Cherepanov (2019a) earlier proposed that when no reasonable solution is available, the decision-making involves weighing and negotiating the following four aspects:
  • Accountability, that is, determination of whom providers are primarily accountable to: the beneficiaries, profession or moral ideals;
  • Contextual awareness, that is, choosing actions that are most beneficial and least harmful to the persons we serve at this particular time and the context;
  • Professional self-awareness, for example, awareness of one’s countertransference, fantasies, and biases and competencies; and
  • Personal self-awareness, for example, knowing the degrees and limits of one’s flexibility in moral convictions, where some depend on a context, while others may not be negotiable under any circumstances.



  Conclusion Top


MH providers work to alleviate suffering, support marginalised and vulnerable groups around the world, and create transformative change in the lives of people and society. In planning MH interventions, it is important to consider that the CPC experience may produce severe trauma, profound distrust of the healthcare system and service providers, and mutual distrust in the community. It often leads to difficulties in disclosing vulnerabilities and reaching out for and accepting help. Research shows that these social cognitions are very pervasive and can continue to dominate the worldview and determine social behaviours for generations to come (Cherepanov, 2020b). This potential for transgenerational toxicity underscores the importance of MH interventions in CPC.

Work in such settings creates ethical ambiguities. Their effective navigation prioritises contextual appropriateness, harm reduction, accountability and self-awareness. To minimise harm, practitioners need to engage beneficiaries in decision-making about the best choice of interventions. This should always be the case, and it is vital in CPCs.

Refugees arriving from countries with CPCs continue to face significant barriers to accessing health care during their resettlement and may need additional support from MH providers when their own community may not be able or willing to support them.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.







 
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