How to safely carry out mobile



How to safely carry out mobile

Mental Health and Psychosocial Case Management

UNHCR Syria

In addition to the fixed MHPSS Case Managers (MHPSS CMs) based at the three SARC clinics in Damascus & Rif Damascus: Al Akram, Al Zahira and Qudsaya, SARC has created mobile CM teams that are visiting 5 collective shelters in Damascus (and Rif Damascus?). Below are a few points to consider for mobile MHPSS CM teams to ensure that a mobile MHPSS case management service focuses upon safety, ethics and quality programming so that we do not unwittingly cause harm to persons of concern.

a) Logistics

• In order to ensure predictability it is suggested that the mobile MHPSS CMs travel to the same sites (community centres, collective sheltes, homes etc.,) on a regular basis with a set route and not to visit different sites each time. For reasons of consistency and building up trust it is important that the persons of concern see the same CM each time.

• Co-ordinate with other agencies providing mobile MHPSS CM services to ensure that each client/ patient only receives one MHPSS CM (which they see on a regular basis) to manage their case.

• Choose a safe, quiet, confidential and well-ventilated location for consultations – designated rooms in collective shelters, designated rooms in community shelters, medical ‘vans’, inside people’s homes.....

b) Identification of patients/ clients with MHPSS needs & concerns

• Difficult to identify possible MHPSS patients in over–crowded shelters. There is often a lack of private consultation rooms/ spaces in the collective shelters so interviewing affected persons is almost impossible to do without causing stigmatisation and further harm. Persons of concern require a safe, calming and quiet space to talk about their thoughts, emotions, feelings and behaviour.

• Survivor centric approach is required – not forcing people to disclose their problems but rather undertaking awareness raising sessions and group activities where people feel safe and secure enough to come forward themselves.

• Assessing the social support structures and overall vulnerabilities of persons of concern is harder for displaced persons living in collective shelters. A more holistics and nuanced approach is often required. Families may have become separated during the displacement, or may have stayed together but they are forced to live in over-crowded and sub-standard conditions where medication can not be kept cold ( in the fridge for example). Similarly over-crowded environments can often scare persons with pre-existing mental health problems.

• A triage or prioritisation system must be in place to screen persons of concern so that only the persons in most need are followed up by a CM. It is important for MHPSS CMs to know the difference between normal stress reactions to the current situation and extreme or abnormal stress reactions that require referral and additional support. There can be a strong risk of over-pathologising or over-referring people if MHPSS CMs are working in crowded collective shelters or community centers due to the high density of people (often visibly showing emotions) and the stressful environment in which they reside. Similarly the threshold to refer a person if he/ she is a danger to herself/ himself should be lower for persons in collective shelters (e.g., persons having a psychotic break, schizophrenic, severely depressed persons at risk of committing suicide) because of issues of over crowding and a lack of privacy which can add to the stress levels of a person with a mental health condition.

c) Tracking of patients, referrals and documentation

• A characteristic of displacement is its unpredictability. A key part of a CM system is the ability to track and contact clients when needed. Clients may move from one collective shelter to another, may move back home or in with relatives, or may choose to leave the area (or country) completely. It is also difficult for displaced persons to charge their mobile phones whilst they are displaced from their houses, making phone contact difficult and unpredictable. Before CMs begin working with a case they need to work out a contact plan with their client, so that the client knows how and who to contact in an emergency and similarly if the CM needs to contact the client. This contact plan will also help to build up trust between the client and CM.

• Forms should be designed specifically for CMs to enable them to document their client’s progress and ensure a continuum of care. UNHCR does not have the mandate nor the capacity to conduct individual CM for Syrians. There is, also, no point doing the pre-Qs if it is not possible to conduct the post-Qs. Forms for mobile MHPSS CMs should also be shorter as persons of concern may not have the time or space to fill in a detailed form whilst in a collective shelter or a community centre. However, some type of pre and post-test forms are mandatory in order to monitor and track the impact of case management services and a clients’ progress (particularly in terms of achievments of goals). These forms are a key part of assessing the quality and effectiveness of the case management approach (i.e., our ability to prove that our interventions are having a positive impact on the client).

• All mobile CM agencies should maintain a database of clients/ patients that they are currently managing and co-ordinate with other agencies providing similar services to prevent any overlap.

• All mobile CMs should record and document all referrals they make on behalf of their client, according to the ‘treatment’ or ‘case management’ plan.

• If referrals are required for further support or specialised services, then the MHPSS CM needs to arrange for someone to accompany their client if they are unable to, for example a PSS Outreach Volunteers or family members.

• The safe storage of client files can be difficult for mobile MHPS CMs. CMs should only carry the files of clients that they are planning to see for the next 1-2 days, with the remainder of the files locked in a fixed location such as a primary health care clinic or in a community centre. Whilst in transit, files should also be kept in a locked case or box and kept in sight at all times.

d) Different job descriptions and terms of reference for mobile MHPSS CMs

• Mobile MHPSS CMs should have a specific ToR to highlight the important differences between their work and the role of fixed MHPSS CMs within multi-discplinary teams and primary health care units.

• Mobile CMs need to be more experienced CMs (as they operate with a lower level of supervision than others), should be independent persons who are able to manage their own work, need to have strong relationships with communities and services in their catchment area. Mobile CMs should be humble, strong, secure and confident enough to move around neighbourhoods in affected areas, to work in collective shelters or community centres under difficult conditions etc.

e) Supervision of mobile MHPSS CMs

• All MHPSS CMs, whether working mobile or in fixed locations, should be supervised and mentored at least on a fortnightly basis. For mobile teams it is much harder, but one possible response is for the Technical Supervisor to follow the mobile CMs on various days of the week and to attend any consultations as relevant.

• Group supervision, mentoring and debreifing sessions should happen every fortnight if possible for mobile MHPSS CMs in a fixed location – such as a primary health care clinic or a community centre.

• All referrals recommended by mobile MHPSS CMs must be signed off by the Technical Supervisor. The exception is for emergency cases requiring urgent hospitalisation (such as persons at risk of suicide, having a psychotic episode making them at risk to persons around them – the threshold for this is lower when living in cramped, over-crowded environments such as collective shelters or with host families).

• Peer support amongst mobile MHPSS CMs on a monthly basis can also be a useful way for CMs to discuss their work, the type of problems they are encountering, can develop collegial and supportive work relationships to overcome any possible isolation that may occur when working in a mobile capacity rather than in a fixed office.

f) Linakges between Psychosocial Outreach Volunteers and Emergency Hotlines?

• Will mobile MHPSS work alongside PSS OVs in collective shelters and in some homes (for people living with host families?) Could work as a pair/ ‘team’?

• Any links between people telephoning the emergency hotline number and follow up through a mobile MHPSS CM afterwards? Should mobile CMs also be part of any hotline emergency response team for patients requiring more specialised care/ emergency services or referrals?

|Essential tool or kit list for Mobile MHPSS Case Managers |

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|Notepad, paper and pens/ pencils. |

|Photo identification badge or card associated with your organisation (should be visible to people). |

|Rucksack, bag that can be completely closed (e.g., by a zip or locked case). |

|Patients/ clients files or notes required for that day. |

|Blank documentation form (pre/ post questionnaires) copies to fill in when meeting clients. |

|Contact list (telephone numbers and names) or MHPSS services in the immediate area (for referrals and information sharing). |

|Blank copies of referral forms. |

|Basic toys for children – crayons, pencils, pens and paper (useful when assessing a young boy or girl). |

|Mobile phone with credit. |

|Tissues (in case a client/ patient begins to cry during the interview). |

|Water. |

|Respectable and semi-smart clothes that are not too expensive or flashy (expensive clothes can embarrass or humilate persons |

|of concern). |

|Personal MHPSS CM notepad or reflections notebook. |

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