Chapter 4: Mental Health Policy and Service Provision :
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Promoting mental health
A wide range of strategies is available to improve mental health and prevent mental disorders. These strategies can also contribute to the reduction of other problems such as youth delinquency, child abuse, school dropout and work days lost to illness.
The most appropriate entry point for mental health promotion will depend both on needs and on the social and cultural context. The scope and level of activities will vary from local through to national levels as will the specific types of public health action taken (development of services, policy, dissemination of information, advocacy and so on). Examples are provided below of different entry points for intervention.
Interventions targeting factors determining or maintaining ill-health. Psychosocial and cognitive development of babies and infants depend upon their interaction with their parents. Programmes that enhance the quality of these relations can substantially improve the emotional, social, cognitive and physical development of children. For example, the USA programme Steps Towards Effective Enjoyable Parenting (STEEP) targeted first-time mothers and others with parenting problems, particularly in families with a low educational level (Erickson 1989). There was evidence of reductions in anxiety and depression in mothers, better-organized family life, and the creation of more stimulating environments for children.
Interventions targeting population groups. By 2025, there will be 1.2 billion people in the world who are over 60 years of age, close to three-quarters of them in the developing world. But if ageing is to be a positive experience it must be accompanied by improvements in the quality of life of those who have reached old age.
Interventions targeting particular settings. Schools are crucial in preparing children for life, but they need to be more involved in fostering healthy social and emotional development. Teaching life-skills such as problem-solving, critical thinking, communication, interpersonal relations, empathy, and methods to cope with emotions will enable children and adolescents to develop sound and positive mental health (Mishara & Ystgaard 2000).
A child-friendly school policy which encourages tolerance and equality between boys and girls and different ethnic, religious and social groups will promote a sound psychosocial environment (WHO 1990). It promotes active involvement and cooperation, avoids the use of physical punishment, and does not tolerate bullying. It helps to establish connections between school and family life, encourages creativity as well as academic abilities, and promotes the self-esteem and self-confidence of children.
Raising public awareness
The single most important barrier to overcome in the community is the stigma and associated discrimination towards persons suffering from mental and behavioural disorders.
Tackling stigma and discrimination requires a multilevel approach involving education of health professionals and workers, the closing down of psychiatric institutions which serve to maintain and reinforce stigma, the provision of mental health services in the community, and the implementation of legislation to protect the rights of the mentally ill. Fighting stigma also requires public information campaigns to educate and inform the community about the nature, extent and impact of mental disorders in order to dispel common myths and encourage more positive attitudes and behaviours.
Role of the mass media
The various forms of the mass media can be used to foster more positive community attitudes and behaviours towards people with mental disorders. Action can be taken to monitor, remove or prevent the use of images, messages or stories in the media that potentially would have negative consequences for persons suffering from mental and behavioural disorders. The media can also be used to inform the public, to persuade or motivate individual attitude and behaviour change, and to advocate for change in social, structural and economic factors that influence mental and behavioural disorders. Advertising, although expensive, is useful for increasing awareness of issues and events and for neutralizing misperceptions. Publicity is a relatively cheaper way to create news to attract the attention of the public and to frame issues and actions to achieve advocacy. The placement of educational health or social messages in the entertainment media (so-called "edutainment"), is useful for promoting change in attitudes, beliefs and behaviours.
Examples of public information campaigns which have used the media to overcome stigma include "Changing minds every family in the land" by the Royal College of Psychiatrists in the UK and the World Psychiatric Association's campaign "Open the doors" (see Box 4.9).
Box 4.9 Fighting stigma
"Open the doors" is the first-ever global programme against stigma and discrimination associated with schizophrenia. Launched by the World Psychiatric Association in 1999,1,2 the goals are to increase awareness and knowledge about the nature of schizophrenia and treatment options; to improve public attitudes to people who have or have had schizophrenia and their families; and to generate action to eliminate stigma, discrimination and prejudice.
The Association has produced a step-by-step guide to developing an anti-stigma programme, and reports on the experience of countries that have undertaken the programme, as well as collecting information from around the world on other anti-stigma efforts. The materials have been put to trial use in Austria, Canada, China, Egypt, Germany, Greece, India, Italy and Spain, and other sites are starting to work on the programme as well. In each of the sites, a programme group has been established involving representatives of government and nongovernmental organizations, journalists, health care professionals, members of patient and family organizations, and others committed to fighting stigma and discrimination. The results of programmes from different countries are added to the global database, so that future efforts benefit from previous experience. In addition, the Association has produced a compendium of the latest information available on the diagnosis and treatment of schizophrenia, and strategies for reintegration of affected individuals into the community.
The stigma attached to schizophrenia creates a vicious cycle of alienation and discrimination leading to social isolation, inability to work, alcohol or drug abuse, homelessness, or excessive institutionalization which decreases the chance of recovery and normal life. "Open the doors" will allow people with schizophrenia to return to their families and to school or the workplace, and to face the future with hope.
1 Sartorius N (1997). Fighting schizophrenia and its stigma. A new World Psychiatric Association educational programme. British Journal of Psychiatry, 170: 297.
2 Sartorius N (1998a). Stigma: what can psychiatrists do about it? The Lancet, 352(9133): 10581059.
The Internet is a powerful tool for communication and accessing mental health information. It is increasingly being used as a means to inform and educate patients, students, health professionals, consumer groups, nongovernmental organizations and the population at large about mental health; to host self-help and discussion groups; and to provide clinical care. With the Internet as source of information, the community will be more knowledgeable and as a consequence will have greater expectations regarding the treatment and care they receive from providers. On the negative side, they will have to analyse and understand a vast amount of complex literature, of varying degrees of accuracy (Griffiths & Christensen 2000). Increasingly, Internet users will expect to receive easy access to treatment and consultation from health professionals, including mental health care providers, ranging from simple inquiries to more sophisticated video-based consultations or telemedicine.
Major challenges are to use this information technology to benefit mental health in developing countries. This requires improved access to the Internet (fewer than one million people of a total of 700 million have access to it in Africa) and the availability of mental health information in a variety of languages.
Using community resources to stimulate change
Although stigma and discrimination have their origin in the community, it should not be forgotten that the community can also be an important resource and setting for tackling their causes and effects and, more generally, for improving the treatment and care provided to persons suffering from mental and behavioural disorders.
The role of the community can range from the provision of self-help and mutual aid to lobbying for changes in mental health care and resources, carrying out educational activities, participating in the monitoring and evaluation of care, and advocacy to change attitudes and reduce stigma.
Nongovernmental organizations are also a valuable community resource for mental health. They are often more sensitive to local realities than are centrally driven programmes, and are usually strongly committed to innovation and change. International nongovernmental organizations help in the exchange of experiences and function as pressure groups, while nongovernmental organizations in countries are responsible for many of the innovative programmes and solutions at the local level. They often play an extremely important role in the absence of a formal or well-functioning mental health system, filling the gap between community needs and available community services and strategies (see Box 4.10).
Box 4.10 The Geneva Initiative
The Geneva Initiative on Psychiatry was founded in 1980 to combat the political abuse of psychiatry as a tool of repression. Despite its name, the international Initiative is based in the Netherlands.
The All-Union Society of Psychiatrists and Neuropathologists (AUSPN) of the former USSR withdrew from the World Psychiatric Association (WPA) in early 1983 in response to pressure from campaigns by the Geneva Initiative, and in 1989 the WPA Congress set strict conditions for its return. The Russian Federation acknowledged that psychiatry had been abused for political purposes and invited the WPA to send a team of observers to Russia. At the same time, increasing numbers of psychiatrists contacted the Geneva Initiative to assist them in reforming mental health care. By then, the situation was changing dramatically: in the preceding two years, virtually all political prisoners had been released from prisons, camps, exile and psychiatric hospitals.
Between 1989 and 1993 the Initiative concentrated on a few Eastern European countries, particularly Romania and Ukraine. It became clear that a new approach to the mental health reform movement was needed. Though many reforms had been undertaken throughout the region and many people had acquired new skills and knowledge, no links existed among the reformers, and there was a lack of trust and unity. With financial support from the Soros Foundation, the first meeting of Reformers in Psychiatry was organized in Bratislava, Slovakia, in September 1993. Since then, over 20 similar network meetings have taken place.
Today, the Network of Reformers unites some 500 mental health reformers in 29 countries of Central and Eastern Europe and the newly independent states, and has links with over 100 nongovernmental mental health organizations. Its members are psychiatrists, psychologists, psychiatric nurses, social workers, sociologists, lawyers, relatives of people with mental disorders, and a growing number of consumers of mental health services. Mostly through this Network, the Geneva Initiative now operates in over 20 countries, where it manages about 150 projects.
The Geneva Initiative strives for structural improvement, and thus concentrates on programmes concerned with reform of policy, institutional care and education. It aims to combat inertia and to achieve sustainability and maintain funding. Last year, the Initiative was awarded the Geneva Prize for Human Rights in Psychiatry.
More information about the Initiative can be found on the web site http://www.geneva-initiative.org/geneva/index.htm
Consumer groups have emerged as a powerful, vocal and active force, often dissatisfied with the established provision of care and treatment. These groups have been instrumental in reforming mental health (WHO 1989). There now exist in many parts of the world a large number of consumer associations with interests, commitments and involvement in the mental health area. They range from informal loose groupings to fully fledged constitutionally and legally created organizations. Although they have differing aims and objectives, they all strongly advocate the consumer's viewpoint.
Authorities responsible for delivering services, treatment and care are accountable to the consumers of the system. One important step towards achieving accountability is to involve consumers in the creation of services, in reviewing hospital standards, and in the development and implementation of policy and legislation.
In many developing countries, families play a key role in caring for the mentally ill and in many ways they are the primary care providers. With the gradual closure of mental hospitals in countries with developed systems of care, responsibilities are also shifting to families. Families can have a positive or negative impact by virtue of their understanding, knowledge, skills and ability to care for the person affected by mental disorders. For these reasons, an important community-based strategy is to help families to understand the illness, encourage medication compliance, recognize early signs of relapse, and ensure swift resolution of crisis. This will lead to better recovery, and reduce social and personal disability. Visiting community nurses and other health workers can provide an important supportive role, as can networks of self-help groups for families and direct financial support.
A couple of cautionary notes are warranted. First, the erosion of the extended family in developing countries, coupled with migration to cities, presents a challenge to planners to utilize this resource for the care of patients. Second, when the family environment is not conducive to good quality care and support, and in fact may be damaging, a family solution may not be a viable option.
Chapter 4: Mental Health Policy and Service Provision :
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