Psychological Interventions for Survivors of Intimate Partner Violence in Humanitarian Settings: An Overview of the Evidence and Implementation Considerations

This paper provides an analytical overview of different types of psychological interventions that have demonstrated efficacy in low-income and/or humanitarian settings and points to special considerations that may be needed if used with women who have been subjected to gender-based violence (GBV). This paper reviews diverse therapeutic modalities and contrasts them across several domains, including their conventional use and principles; their documented use and efficacy in humanitarian settings; any special considerations or modifications necessary for GBV-affected clients; and any additional resources or implementation concerns when working in low-income contexts. By examining the evidence base of multiple interventions, we hope to provide clinicians and GBV-prevention advocates with an overview of tools/approaches to provide survivor-centered, trauma-informed responses to GBV survivors. This analysis responds to the growing recognition that gender-based violence, in particular intimate partner violence and sexual violence, is strongly associated with mental health problems, including anxiety, depression, and post-traumatic stress. This is likely to be exacerbated in humanitarian contexts, where people often experience multiple and intersecting traumatic experiences. The need for mental health services in these settings is increasingly recognized, and a growing number of psychological interventions have been shown to be effective when delivered by lay providers and in humanitarian settings.


Introduction
Gender-based violence (GBV) has been shown to have profound, negative impacts on psychosocial and mental health, and presents a global challenge to gender equality, equity and safety. Women who experience GBV can face rejection from their families and communities, experience stigma and be exposed to ongoing risks of violence [1]. GBV survivors also experience higher rates of mental disorders such as depression [2], post-traumatic stress (PTS) [3], and anxiety disorders [4], and are more likely to have attempted suicide. There also appears to be a bidirectional relationship between GBV and mental health problems, in that experiencing GBV seems to increase the likelihood of developing mental health problems, while mental health problems increase the risk of experiencing GBV.
Globally, nearly one in three women (30%) will experience physical and/or sexual intimate partner violence (IPV) or sexual violence by a non-partner in their lifetime [5] and the risk of GBV often grows more acute in humanitarian contexts [6]. A study from South Sudan indicated that up to 65% of women there reported experiencing intimate partner and sexual violence [7], and countries affected by conflict were among those with the highest prevalence of IPV [5]. Humanitarian contexts also pose a particular challenge for addressing the mental health needs of survivors, as health systems can be severely compromised, mental health services may be lacking or non-existent, and access barriers, particularly due to displacement and insecurity, can increase.
There is evidence that adapted, culturally-relevant mental health programming is an effective tool for addressing poor mental health in humanitarian contexts [8][9][10][11], and research related to mental health interventions for GBV survivors is promising albeit limited. There is some evidence that mental health interventions can reduce the impact of intimate partner violence in humanitarian contexts [12], and that involvement in mental health interventions can improve outcomes related to depression, PTS, and substance use problems [13,14], though there are limited numbers of high-quality studies available [14]. Psychological interventions such as cognitive behavioral therapy, acceptance and commitment therapy, eye movement desensitization and reprocessing (EMDR), and the common elements treatment approach (CETA) have been implemented in humanitarian settings. Moreover, there is a growing body of evidence to suggest that interventions conducted by paraprofessionals and trained lay providers can be effective for common mental disorders [15]. This is particularly important in light of the limited resources (human, financial and organizational) available for mental health in most countries and particularly in lowand middle-income contexts [16].
In addition to questions about effectiveness, questions also remain about what types of interventions are best suited to GBV survivors, whether GBV survivors need tailored interventions and whether existing interventions may be problematic if applied without attention to the particular dynamics of GBV, particularly intimate partner/domestic violence where the violence often is ongoing. Mental health problems for GBV survivors occur within a social and cultural context of gender inequality, discrimination, normalization or acceptance of violence against women, and stigma. This broader context shapes the mental health outcomes of survivors and, we posit, should be considered by health and mental health providers when working with this specific population. The purpose of this review is therefore to identify effective mental health interventions that have been used for survivors of GBV, explore their relative strengths and limitations, and list any potential considerations specific to working in humanitarian contexts. Our goal is to provide an overview of potential interventions and their implementation considerations for clinicians and GBV programming advocates to refer to when developing a combined GBV and mental health program.
In this we review, we identify and discuss a range of psychological interventions that have demonstrated efficacy in low-income and humanitarian settings and point to special considerations that may be needed if used with women who have experienced GBV in humanitarian or resource-poor settings. We reviewed numerous therapeutic modalities and contrasted them across several domains, including their conventional use and principles; their documented use and efficacy in humanitarian settings; any special considerations or modifications necessary for GBV-affected clients; and any additional resources or implementation concerns when working in low-income contexts. By examining the evidence base of multiple interventions, we hope to provide clinicians and GBVprevention advocates with an overview of tools/approaches to provide survivor-centered, trauma-informed responses to GBV survivors.

Methods and Search Strategy
The original purpose of this review was to inform a manual for clinicians and GBV advocates. This review was intended as a reference for potential interventions to consider when including mental health services in novel GBV intervention programs and vice versa.
The articles, books and chapters consulted in this desk review were identified across PubMed, Google Scholar, and PsycINFO. We included peer-reviewed, published articles, published book chapters, and reports from non-governmental organizations related to the development and testing of mental health and psychosocial services programming in low-income and humanitarian contexts. The search included three phases taking place in May 2020. The first phase identified well-established mental health interventions with at least one trial in a humanitarian context. Our search strategy included all articles published within the last 20 years. Trials must have been conducted in a low-income or humanitarian context. The type of mental health intervention used, effect sizes, whether the sample was GBV affected, and what, if any, adaptations were made to the intervention were all noted. Articles were excluded if: (1) they were published before the year 2000; (2) if the study design was not either a randomized-clinical trial or in a comparative group format; (3) if the study was not conducted in a humanitarian or low-income context; (4) if the article was not peer reviewed; (5) if the sample included children; and (6) if the investigation was not conducted in a low-or middle-income context. The search terms used for this initial phase are included in Appendix A.
The second phase involved consulting clinical guidebooks and peer-reviewed literature that explained the principles and guiding practices of each individual intervention identified in the previous phase. The purpose of this phase was to identify and explore the concrete principles required for meaningful clinical implementation of a given intervention, and explore its feasibility in a resource-poor context.
In the final phase, we consulted literature related to potential modifications to a given intervention that would better suit a GBV-affected population in a humanitarian context when available. Our search strategy was informed by published materials identified in the first two phases, broadened to include work that specifically identified modifications, practical changes, adaptations, or other changes that lead to a significant difference in clinical efficacy when working with GBV-affected women.
An initial draft of the findings based on the above reviews was reviewed by co-authors ER and CGM, along with invited collaborators with expertise in both the GBV-prevention and mental health fields. This helped to both identify novel articles and resources, and to further develop content into a viable reference for both GBV and mental health servicesfocused audiences.

Results: Psychological Intervention Modalities
The results of the literature review and expert consultation are presented below, grouped by primary intervention modality. We identified eight potential interventions based on the three phases of review. We have presented a brief overview of the basic tenets of a given intervention, followed by evidence of efficacy and implementation considerations. We have also provided a table summarizing the findings (Table 1) as a reference for practitioners to see the benefits of these interventions side by side.

Cognitive Behavioral Therapy (CBT) and CBT-Based Techniques
Cognitive behavioral therapy (CBT) has been the dominant approach to psychotherapy in both research and practice for decades [17]. Its core tenets are identifiable across many interventions that show promise when working with survivors of GBV-delineating between thoughts and feelings, challenging maladaptive cognitions, and developing healthier behavior patterns that support psychological well-being. However, calls for plurality in treatment orientation [18], and increased interest in flexible interventions that can address multiple problems [19] have led to many potential responses seeking to improve mental well-being through mental health programming in a more scalable way. Table 1 summarizes key principles, implementation considerations and evidence summaries for each of the therapeutic modalities for which evidence is available.
Cognitive processing therapy (CPT) was developed specifically for survivors of sexual violence, and is typically used to address symptoms of PTS, though it has some efficacy in reducing symptoms of other common mental health problems such as depression and anxiety [20]. The findings of two meta-analyses [21,22] have indicated that CPT may be the most effective treatment for PTS symptoms (compared to other psychotherapies and medications) across several traumatized groups. While originally designed to address symptoms of PTS among survivors of sexual violence, CPT has shown effectiveness among other trauma-exposed populations via different modalities (e.g., combat veterans via teletherapy [23] and active duty military clients in group contexts [24]). Session content for CPT mirrors typical cognitive behavioral therapy. The activities are all built on challenging the client's appraisal of traumatic events to shed light on a healthier narrative.
In a trial conducted among sexual violence survivors in the Democratic Republic of Congo, there was a significant reduction in depression and PTS symptoms within the treatment group, as well as decreased stigma regarding sexual violence [25,26]. Recent results currently under review suggest that those symptom reductions have persisted beyond the initial trial-in a four-year follow-up, the same participants reported both lower depression and PTS scores, as well as specific knowledge and implementation of CPT skills they had learned from their therapy sessions four years prior. Participants continued to practice CPT skills to alleviate psychological distress even though CPT groups were no longer officially meeting. In a qualitative investigation from the same four-year follow-up study [27], practitioners retained CPT skills and maintained CPT groups with new clients despite a lack of institutional support and clinical oversight, indicating some degree of sustainability with limited resources. While CPT can be delivered in group or individual settings by trained psychotherapists, paraprofessionals, or lay providers, there is little evidence to date regarding its integration into extant GBV or health service infrastructure.
The common elements treatment approach (CETA) encompasses elements of several cognitive and behavioral therapies. The CETA is intended to be transdiagnostic-it does not explicitly address the symptoms of a single diagnosis but seeks to address psychological distress and well-being more broadly, independent of potential diagnoses. The CETA can address symptoms of depression, anxiety, and PTS. While modular therapies were developed in the United States [28,29], the CETA itself was specifically designed for use in low-income and humanitarian contexts. Modules were developed based on systematic reviews and meta-analyses of numerous therapies, and composed based on expert consultation and peer review [30]. Depending on symptom scores across three domains (i.e., anxiety, depression, and PTS), different modules related to each specific problem area can be included and reordered to better suit the pressing needs of an individual client. At twelve sessions, it is somewhat time intensive, though a shorter, five-session version is currently being evaluated among conflict-affected veterans in Ukraine [31].
RCTs for the CETA conducted in Thailand [32], Zambia [33], Iraq [34], Iraqi Kurdistan [35], Colombia [36], and Somalia [37] have all indicated significant positive effects on mental health outcomes for men, women and children. There is evidence for effectively addressing the incidence of GBV after incorporating safety planning and substance use programming for partners concurrently receiving the CETA, which in turn suggests that mental health programming alone may reduce the likelihood of IPV [33,38]. In a trial in Zambia, a CBT-oriented substance use component was introduced for men, while women and family members received session content related to substance support content to help facilitate discussion of drinking, its triggers, and problem behaviors more effectively. Additional safety planning and support were also included as part of the original safety module. Trials have been conducted across a variety of delivery settings, from homes to clinics to refugee camps, suggesting potential for adaptation to multiple contexts. The CETA is perhaps most resource intensive in its training and implementation. Providers must undergo at least two weeks of intensive training by certified trainers of trainers (TOTs), who in turn provide remote clinical supervision and booster training. To date, the CETA has not been integrated into extant aid programming (e.g., anti-poverty programming or GBV-specific programming) and has been typically implemented as a standalone intervention with its own infrastructure.
Interpersonal psychotherapy (IPT) is considered a benchmark approach to treating depression. IPT is rooted in CBT but incorporates attachment theory and contemporary psychodynamic theory to focus specifically on how a client's relationship to others can influence well-being. IPT begins by identifying one of four potential problem areas that is contributing to psychological distress: interpersonal disputes, role transitions, grief and loss, and interpersonal sensitivity [39]. These factors represent a triggering point that, in conjunction with the biopsychosocial elements unique to the individual, results in distress. Though IPT is focused on addressing depression symptoms, successful trials in the developing world (e.g., Bolton et al., 2003) have relied on extensive qualitative research and adaptation to include both idiomatic expressions of mental health symptoms unique to a given context.
One of the first landmark trials of a mental health intervention in a low-income context examined the effect of group IPT provided by a trained lay provider among men and women in rural Uganda [40]. The results demonstrated reduced depression symptoms and improved daily functioning (i.e., the ability to perform tasks required for daily living) among group participants. A pilot trial in Egypt among Sudanese refugees reported decreased depression and PTS symptoms among its participants [41]. There is additional evidence that supports efficacy among GBV survivors-an RCT in Kenya among HIV-positive women affected by GBV reported support for both the content and structure of a group IPT intervention, as well as its feasibility [42,43]. Given its effectiveness in treating depression, the WHO has released an adapted and translated manual for group IPT, and recommend it as a "first-line" treatment for depression [44]. While shorter versions have been manualized and tested in the US primary care setting (see Interpersonal Counseling [45]), IPT can be intensive, covering 16, 90 min sessions in the full-format version.
Problem management plus (PM+) is a recent development within the field of interventions for low-income settings, including humanitarian settings. PM+ was conceptualized by the WHO as part of its scalable interventions initiative [46]. PM+ is transdiagnostic, and incorporates strategies related to problem solving and behavioral therapies to address several domains related to psychological well-being-managing stress, managing problems, behavioral activation, and strengthening social support. PM+ is intended to meet task-shifting requirements in settings where more intensive psychotherapy might not be readily available. As such, it is being tested in low-income settings. Given its relative novelty, the evidence base for PM+ is still in development. A subgroup analysis from a fully-powered RCT in Kenya specifically examining GBV-affected women indicated moderate reductions in general psychological distress after a 3 month follow-up [47], while an RCT among women in conflict-affected rural Pakistan demonstrated significant reductions in depression and anxiety symptoms [48]. Pilot findings from the same trial indicated positive findings regarding the intervention's feasibility, uptake, and acceptance by participants [49]. While GBV survivors have been included in subgroup analyses during initial testing, there are no specific recommendations for use when working specifically among GBV-affected groups. PM+ has potential to be a highly scalable intervention platform for use by nonspecialists and specialists alike. There are existing manuals that have been adapted and translated into multiple languages available. At five 90 min sessions, it is among the shortest of interventions de-scribed. While individual treatment has been tested in two RCTs, a group adaptation is currently in development and being tested [50], and will consist of five three-hour long sessions of eight participants per facilitator. PM+ is not designed for severe mental health problems and is intended to be used with individuals with depression, anxiety, or PTS symptoms of moderate severity who require additional support beyond what is available in a given community.

Third-Wave Cognitive and Mindfulness-Oriented Therapy
Acceptance and commitment therapy (ACT) incorporates elements of cognitive therapies and mindfulness-based activities to address mental health symptoms. The evidence base for ACT is still growing, but early studies and an updated meta-analysis of clinical trials indicates that it is efficacious in treating multiple psychological problems including depression, anxiety, and PTS symptoms [51]. ACT is unique in its emphasis on cultivating present-mindedness-using techniques to emotionally and cognitively "ground" one's self in the present moment-to address mental health problems and distress. ACT is focused on identifying, clarifying, and ultimately enacting a client's values [52]. These values are client-selected components of life that the client finds rewarding, reinforcing, and ultimately critical for well-being. Its emphasis is less on attempting to remove psychological distress than on acknowledging its existence, and identifying ways to safely and constructively work around it [52]. As a transdiagnostic approach, ACT is potentially well suited for broad-based service platforms (e.g., community-level interventions) but more research is needed. There is evidence to support the use of ACT and ACT-based interventions in both group and individual applications, with both trained lay providers and psychological professionals. ACT is not session limited or structured, and as such does not have a fixed implementation timeline, which may require additional adaptation on behalf of the provider.
The evidence for ACT's efficacy in humanitarian settings is limited, but growing. A cadre of counselors in Sierra Leone were recently trained in ACT with high fidelity and uptake, which suggests feasibility in scaling up services conducted by paraprofessionals [53]. The World Health Organization (WHO) developed an ACT-based guided self-help intervention as part of its scalable psychotherapy initiative [46], Self-Help Plus (SH+) [54]. SH+ relies on a printed guidebook and audiovisual sessions to provide ACT-based coping skills for large groups (20-25 participants) experiencing mild to moderate psychological distress. In an RCT [55] among South Sudanese refugee women, SH+ was associated with moderate reductions in general psychological distress, depression, and PTS symptoms. Within the sample, 26% of women reported IPV, 10% reported sexual violence, and 7% reported sexual violence by someone other than their partner.
Contemporary research is beginning to focus more on the potential for yoga, bodyoriented, and mindfulness-based approaches to address negative mental health symptoms among survivors of GBV. There is a notable link between the experience of traumatic stress and biophysical/neurological problems [56,57], and meditation/mindfulness-based interventions are centered around that link. The goal of mindfulness-oriented interventions for psychological distress is to increase personal insight and improve self-referential processing [58], or one's ability to understand and process emotions in a meaningful way. For example, trauma-sensitive yoga (TSY) combines physical poses, focused breathing, and mindfulness practice as an intervention for traumatic stress [59]. In one RCT, women with chronic, treatment-resistant PTS problems who completed a 10 week TSY program experienced a significant reduction in PTS symptoms that were sustained for a greater length of time compared to women who received only conventional talk therapy [60]. In a follow-up study among the same participants, women who continued their TSY practice had greater likelihoods of lower PTS symptoms at reassessment [61]. While clinical evidence is limited, these findings suggest the potential longitudinal effects of sustained TSY practice on mitigating trauma symptoms. Feasibility and case studies [62,63] show that TSY is a promising intervention specifically for survivors of intimate partner violence, but there are no robust investigations among that population. Similarly, there is little to no available research examining TSY in humanitarian or low-income settings, though one small study in Uganda shows promising results [64]. TSY sessions are conducted by trained, certified instructors, which may limit its feasibility in certain contexts. However, the premise of combining light physical activity, breathing, and mindfulness activities could potentially be implemented through trained lay providers.

Exposure-Oriented Interventions
Eye movement desensitization and reprocessing (EMDR) was conceptualized as a safer therapeutic approach to imagined exposure therapy for traumatic events. EMDR posits that negative thoughts, feelings, emotions, and behaviors are the result of lingering memories of a potentially traumatic event. The primary theory, the adaptive information processing hypothesis, suggests that the process of repetitive, side-to-side eye movement triggers a cognitive state that ultimately facilitates information processing. EMDR has been considered a highly effective treatment for PTS symptoms, including among survivors of sexual violence [65], though recent meta-analysis findings suggest that it is not effective for addressing other problems long term [66].
EMDR has limited testing in humanitarian contexts, with mixed findings. A trial conducted with Syrian refugees [67] indicated mild symptom improvement, but reported issues with treatment fidelity and attrition. Successful training of psychological professionals has been reported in the Arab world [68], as well as natural disaster-affected and humanitarian settings in Asia [69]. No studies have been conducted in an international context specifically among GBV-affected groups, though the intervention itself was developed specifically for survivors of traumatic events. EMDR has been endorsed by the WHO's violence against women guidelines as a potential intervention to address mental health problems stemming from exposure to sexual violence [70].
While there is a substantial number of studies that indicate EMDR's potential for treating symptoms of PTS, a recent meta-analysis suggests a high risk of bias across many of the studies included, and relatively small effect sizes for treatment efficacy [66]. Moreover, the study indicated limited evidence for reducing comorbid symptom severity among several common mental health problems including depression, anxiety, and sub-stance use problems. No studies to date have examined EMDR's potential as a group intervention, or with therapy conducted by lay providers in humanitarian contexts. As such, it may require intensive training, clinical supervision, and access to psychological professionals for implementation, or considerable adaptation for task-shifting approaches, and is therefore unlikely to have broad applicability in resource-poor settings with limited numbers of trained professionals.
Narrative exposure therapy (NET) is a short-term intervention that draws on a variety of disciplines. NET has been used effectively with children and adults across a variety of settings, including refugee and humanitarian contexts [71][72][73]. NET is designed to be used in low-resource contexts and relies on qualitative and anthropologically oriented techniques to place trauma and related distress in cultural context. NET has been used across multiple humanitarian contexts, including in some of the earliest trials of MHPSS interventions in low-income settings [74,75]. Meta-analysis data from several studies assessing NET administered by trained lay providers in refugee settings have shown moderate effect sizes for the treatment of PTS [72]. An RCT of female former child soldiers in the DRC demonstrated the efficacy of a group version of NET in reducing PTS, depression symptoms, and aggressive behaviors in the midst of ongoing conflict [76]. No specific modifications have been identified for working with GBV survivors. As a trauma-focused intervention, NET accommodates a range of potentially traumatic events.
The trials cited above provide evidence for the efficacy of both group and individual versions of NET. Given its emphasis on embracing culture and context, NET prioritizes training local partners and paraprofessionals as providers, though psychology professionals could also be trained. NET consists of ten 60 to 90 min sessions and requires approximately ten days of training for facilitators. Given its reliance on text and writing, it may not be well suited for low-literacy populations. However, alternative practices to accommodate clients are available (e.g., relying on art, photography, or spoken word). • ACT-based programming for GBV survivors may specifically emphasize issues of experiential avoidance [77], e.g., using present-moment awareness skills when walking past the site of a sexual assault to mitigate psychological distress, decrease avoidance behaviors, and promote positive coping strategies for negative thoughts/feelings. • Possible risk of respondents accepting abuse as inevitable. Primer for facilitators that highlights the risks of working with GBV-affected groups is strongly recommended.
• Transdiagnostic approach suits more broad-based service platforms, but evidence base is limited. • Group or individual applications possible, with lay and professional providers.

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Training can be intensive (two or more weeks) or simplified (one week) depending on session content.

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No inherent session count but some interventions such as SH+ rely on five two-hour sessions in groups of 20 or more participants, in addition to a manual and audio sessions. • Audio sessions and manual are available in multiple languages online. • Reduced depression and functional impairment among conflict-exposed men and women in Iraqi Kurdistan.

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Reduced depression and PTS symptoms among men and women exposed to conflict in southern Iraq.

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The theory of change for EMDR is unclear but is typically explained using the adaptive information processing hypothesis; that the process of eye movement triggers a state that facilitates information processing and allows clients to overcome traumatic experiences safely.
• Evidence is a bit mixed-small trial among Syrian refugees reported mild improvements despite fidelity and attrition problems [67]. • Similar findings have been reported in the conflict-affected parts of the Arab world [68], and natural disaster-affected and humanitarian settings in Asia [69], though the studies involved are of mixed quality.

•
No studies specifically addressing GBV-affected populations.
• Like other therapies listed here, EMDR was developed specifically for trauma survivors, including women exposed to GBV and sexual violence.

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No specific adaptations to address GBV.
• Evidence base shows consistent effectiveness across variety of contexts, but recent meta-analysis indicates a high risk of bias across many studies and small effect sizes [66].

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No studies to date have examined group sessions or therapy conducted by lay providers, which may limit feasibility in certain contexts.

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Highly specialized intervention specifically for traumatic stress, with limited evidence of reducing comorbid mental health symptoms. • Manuals/training must be purchased.

Interpersonal Psychotherapy (IPT)
• Developed in the US as a dedicated intervention for major depressive disorder [79]. • Strong cognitive roots, but focuses more on relationships between client and environment/others. • Basic premise is that how we relate to others can drive psychological well-being. • Treatment is based on the identification of one of four problem areas: interpersonal disputes, role transitions, grief and loss, and interpersonal sensitivity [39]. • Therapist uses communication analysis-a way to investigate how interpersonal difficulties are linked to expression/communication.

•
One of the first trials of an MHPSS intervention in humanitarian settings involved using group IPT among men and women in Uganda [40]. Significant effects for reduced depression and improved daily functioning. • A pilot trial in Cairo, Egypt among Sudanese refugee men and women noted decreased depression and PTS symptoms [41]. • Work in Kenya [42] among HIV+ women, many of whom were affected by GBV, reported support for both group IPT and its feasibility.
• Dedicated depression intervention with mixed evidence for other common mental health problems. • Limited research looking specifically at the efficacy of IPT within GBV-affected populations-one study developed a specific manual for working with survivors of sexual violence [80]. • Emphasis on interpersonal relationships could be beneficial for addressing depression and anxiety associated with GBV exposure, though limited evidence and few trials.

Discussion
This review provides a brief review related to specific psychological interventions for addressing mental health problems among survivors of IPV or sexual violence in humanitarian settings, as well as specific considerations for working within those contexts. Transdiagnostic treatments that can be delivered by paraprofessionals or trained lay providers have the potential to reach many survivors in need, and have been shown to reduce mental health symptoms, as well as general psychological distress.
Contemporary research is moving towards a less medicalized approach to mental health, a greater emphasis on transdiagnostic, broad-based approaches with greater scalability, i.e., programs that avoid building entirely new infrastructures to address single mental health diagnoses. Contemporary practice is looking more to integrating mental health/psychological interventions into broader social intervention programs, such as incorporating mental healthoriented programming into violence prevention or poverty alleviation initiatives. In addition, mental health providers/services need to better integrate violence prevention given the prevalence of GBV and its association with mental health problems. Highly specialized mental health programming is not a panacea for addressing psychological well-being in complex emergencies. Adapting specialized mental health treatments with a dedicated diagnostic focus to make them more scalable and more easily implemented as community and family supports should be the focus of future programming.
Future research may seek to demonstrate the potential for broad-based mental health programming as a preventative intervention, e.g., integrating basic psychological screening and stress management skills training into primary care or community centers in an effort to prevent development of more severe symptoms. There is some evidence that psychological/psychosocial interventions can contribute to reductions in violence [12,14].
There is a notable gap in that many of these studies fail to include men in trials, despite evidence that psychological distress in men is associated with an increased likelihood of living in poverty, abusing alcohol, and perpetrating partner violence [83,84]. Evidence suggests that addressing men's mental health and substance issues may decrease the likelihood of violence perpetration [33]. Research in this area might provide insight into strategies that mitigate both violence and poor mental health. Studies conducted among men in the several low-income and humanitarian settings suggest a link between men's exposure to violence in early adulthood and an increased likelihood of perpetrating IPV [85,86]. The same study indicated that men typically seek psychological coping strategies that reaffirm heteronormative gender expectations of male dominance, including alcohol use, physical/psychological abuse, and abandoning romantic partners who have experienced sexual violence [85]. As such, mental health approaches that simultaneously address life course exposure to potentially traumatic events, psychological distress, and broader sociocultural issues concerning masculinity and power may prove more effective in reducing GBV. Similarly, concurrent interventions that can address substance and alcohol abuse, such as motivational interviewing, may increase the likelihood of finding healthier coping strategies and reducing violence.
This study is presented with some limitations. While the authors did follow a standardized approach to identifying interventions in the literature, exploring their principles, and examining the extent to which they would be feasible in humanitarian context, this is not a systematic review. As such, it is not a comprehensive evaluation of the overall status of the field, or of broader therapeutic efficacy within these circumstances; however, it does provide valuable insights into the extent to which these interventions are adaptable to GBV or humanitarian settings and adjustments necessary for successful implementation.

Conclusions
Although this review does not rely on the conventional systematic review approach, we believe that a review with a more programmatic/clinical perspective on identifying and implementing evidence-based mental health programming will be useful to mental health practitioners and GBV advocates and practitioners to understand what evidence is available for different types of psychological interventions. Ultimately, these interventions and their associated research are critical steps in advancing mental health programming to a point where it can be safely integrated into established programming in a less intensive, more community focused way that remains beneficial to communities affected by GBV. Institutional Review Board Statement: Ethical review and approval were not required for this review as it did not involve humans or animals.
Informed Consent Statement: All articles included in our review included informed consent, and were subject to internal review.

Acknowledgments:
In this section you can acknowledge any support given which is not covered by the author contribution or funding sections. This may include administrative and technical support, or donations in kind (e.g., materials used for experiments).