Caring for Carers: A psychosocial supervision intervention for mental health practitioners
Abstract
There are over 100 million forcibly displaced people worldwide, many of whom suffer mental health problems. There are a profound shortage of mental health professionals to provide specialized mental health treatment in displacement settings, precluding access to services and exacerbating mental health problems. The Caring for Carers project strengthens the ethical and quality provision of mental health services in Northwest Syria, Türkiye, and Bangladesh through online professional support and skills development. Our community-based participatory research project builds on a decade-long partnership with Syrian and Rohingya community members, mental health practitioners, and activists. Our project involves regular consultations and discussions with stakeholders, including co-design and co-delivery of online professional support. We tailor our strategies to address challenges related to inclusive research practice and ensure the meaningful participation of displaced communities as research partners.
Introduction
Our partners are Prof. Muhammad Kamruzzaman Mozumder, a global mental health scholar and clinical psychologist at Dhaka University; Bangladesh Assoc. Prof. Ceren Acarturk, a global mental health scholar and clinical psychologist at Koc University; and Türkiye Hope Revival Organization, a Syrian-run non-governmental organization providing mental health services to displaced Syrian individuals in Türkiye and Syria. Our partners are the research leads in their respective settings, involved in identifying needs and developing the research agenda to ensure the quality provision of mental health services for displaced communities. They lead the design, delivery, and dissemination of the research. In addition, they oversee day-to-day research activities such as data collection, communication with partner organizations, and the delivery and design of the supervision program.
Who should benefit?
Conflict and persecution have led to the displacement of more than 100 million people globally. In this project, we are working with the most deprived communities in Northwest Syria, Türkiye, and Bangladesh. This project aims to strengthen mental health services for Syrian and Rohingya displaced communities. We are developing a model and evidence for the effectiveness of online professional support and skills development to support staff and improve service quality and sustainability.
Since the onset of civil conflict in Syria in 2011, the Syrian crisis has remained one of the most protracted conflict situations. 13.3 million people were profoundly affected. Of them, 6.6 million sought refuge in neighboring countries including Türkiye, which hosts the highest number of Syrians. 6.7 million were forced to leave their homes and currently live in camps in Syria.
Another context of forced displacement is the Rohingya crisis in Myanmar. Rohingya people have endured decades of violence and forced displacement as an ethnic minority in Myanmar, including human rights violations, oppression, and persecution. Since 2017, almost 1 million Rohingya have fled to the Cox’s Bazar district of Southern Bangladesh, where they are confined to congested camps with limited access to basic services or human rights protection.
There are unmet mental health needs among both Syrian and Rohingya displaced communities. Conflict-related traumatic experiences and displacement-related stressors adversely impact mental health and increase the risk of developing mental disorders. Yet there is a profound shortage of mental health professionals to provide specialized mental health treatment in Syria, Türkiye, and Bangladesh. This precludes access to mental health services and exacerbates mental health problems. Low-intensity, scalable psychosocial interventions delivered by non-specialist mental health practitioners are the most viable option for providing mental health care to displaced communities.
Supervision is emotional and practical professional support provided to mental health practitioners to improve their skills and well-being. It is the main pillar to ensure the quality of care provided by practitioners and the sustainability of psychosocial services. By providing online supervision to the practitioners working with displaced Syrians and Rohingya, this project contributes to and strengthens the ethical and quality provision of mental health services provided to these displaced communities.
Engagement
Our community-based participatory project builds on decade-long partnerships with Syrian and Rohingya community members, mental health practitioners, and activists. This work is funded by Elrha’s Research for Health in Humanitarian Crises Program between 2021 and 2024. Study activities are coordinated by local universities in Türkiye and Bangladesh alongside a Syrian-run non-governmental organization in Syria.
Our project design was informed by systematic engagement with service users, practitioners, local and international NGO managers, Ministry of Health, and UN and WHO mental health working groups using focus groups or regular consultation meetings with stakeholders. Based on the insights from our community engagement activities, we moved from WEIRD supervision (Western Educated Industrialised Rich Democratic) to developing a model for WONDERFUL supervision (Western origin; Opportunities sharing; Needs-based; Decolonial; Exchange of knowledge and skills; Respectful and reflexive; Flexible; Useful; Linking and collaboration). We have overcome barriers to center the perspectives of Syrian and Rohingya displaced communities. Having a Syrian-run organization as a research partner and partnership with a Turkish university enables us to ensure the active and meaningful involvement of Syrian displaced people as they lead the project design, implementation, and evaluation in Syria and Türkiye.
However, we encountered significant structural barriers to the inclusion of Rohingya people as active project partners. Rohingya people are Stateless as they are not recognized by Myanmar as their citizens. The Bangladesh government does not have the capacity to provide permanent residence to Rohingya people as Bangladesh is already the most densely populated country in the world, with high levels of poverty and internal migration due to the effects of climate change. Except for the camp context, Rohingya people in Bangladesh have no access to paid employment, formal education or freedom of movement. Based on our long-term grassroots community relationships, we initiated an informal anonymous Rohingya advisory committee. We included Rohingya people not only as the target group of our project, but as equal partners in decision-making. We tailored our strategies to address challenges related to inclusive research practice and ensure the meaningful participation of displaced communities as research partners. Based on the equity principle to address structural barriers for equal representation, we mutually decided to prioritize the visibility of local partners in project outputs while giving credit to all contributors
Research
Our research addresses a gap in data about the effectiveness of online supervision in humanitarian settings. Our project includes systematic data collection from 100 mental health practitioners over 22 months to evaluate the impact of the online supervision program on well-being and clinical efficacy. We are interviewing 1,920 displaced Syrian and Rohingya mental health service users to understand how supervision impacts the quality of the service practitioners provide.
In Syria and Türkiye, mental health practitioners are Syrians providing psychosocial support to their community. In Bangladesh, mental health practitioners are Bangladeshi, providing psychosocial services to the Rohingya community as Rohingya people have restricted work rights. Our decolonial approach seeks to disrupt assumptions Western expertise on mental health carry greater validity than local understandings of distress in the fields of psychology and psychiatry. Our participatory research blends local and international knowledge by including Australian and local clinical co-supervisors and building on local traditions, such as Islamic reflective group conversations with Imams. We exchange knowledge with local mental health practitioners by including them as researchers and collaborating to develop culturally informed qualitative coding frames to understand the supervision process. We iteratively evaluate our research design, data collection strategies, and delivery of the supervision program.
The current project spans 22 months of data collection, including a 6-month active control period and a 16-month online supervision program. In the active period, we collected data from mental health practitioners and service users to establish baseline data to compare against the supervision program. This quasi-experimental design highlighted intervention effects without denying the control group access to the intervention. Using a standardized service satisfaction measure, we noticed the Syrian and Rohingya people service users gave consistently high ratings, which did not help us to understand areas for service improvement. With practitioners, displaced service users, and local researchers, we co-designed a new patient experience measure to capture fine-grained aspects of mental health service experiences. The new measure aims to uncover what is happening in the session and what service users want more or less of. This measure identifies the barriers and enablers to receiving culturally appropriate quality mental health services. We hope it can be used in other humanitarian settings to improve service quality.
