Community mental health
Tony Naidoo, Sherine van Wyk & Ronelle Carolissen
After studying this chapter you should be able to:
•conceptualise what is meant by community mental health
•critique the traditional biomedical formulations of mental health
•understand the ecological model of development and the three constituent domains of well-being
•differentiate between protective factors and risk factors affecting mental health
•describe the historical context for mental health provision and resources in South Africa
•describe and critique mental health provision from a primary health care approach
•provide a schema to describe community mental health interventions.
Yolisa, like many people, had imagined that psychologists worked mainly with individual patients in a consulting room. As she read about community psychology, though, it made perfect sense that psychologists should also take each person’s broader environment into account when they thought about the best way to intervene. Her own experience of growing up in a township had taught her a great deal about the importance of a community.
Her neighbourhood had been a particularly supportive one where the women would often get together to talk about general issues for the community and how to improve things for everyone. Her mother had been involved in one particular group where they had helped to set up a crèche for the younger children who had nowhere to go when their parents went to work. Yolisa thought that if psychologists could help facilitate this kind of activity within communities, they would be able to reach many more people than they would if they only counselled one person at a time.
Thinking about her community though, Yolisa was forced to acknowledge that there had also been a great many problems that were common to the people living there. While her own family had lived reasonably well on her father’s salary, many of those in the surrounding houses had been unemployed and struggled sometimes even to feed their families. Often the families who had more, like her own, would share with others. While this kind of community support was very important, it did not take away the problems that came along with unemployment. Some of the younger men who couldn’t get jobs would hang around on the streets, sometimes drinking and fighting. Although other people in the community got angry with them for doing this, they also understood that the young men were frustrated and angry at not being able to find work. Yolisa could see from this kind of situation that it was just as important for psychologists to think how to change people’s environments as it was to focus on changing the people themselves. An intervention that helped to reduce unemployment in her community might have done a great deal to prevent social and psychological problems from developing.
There is a growing realisation worldwide that the health, quality of life, progress and prosperity of individuals are dependent on the health and well-being of their communities. According to the World Health Organization (n.d.), epidemiological studies indicate that various social stressors, such as violence, alcohol and substance abuse, poverty, suicide, stress and HIV/AIDS are indicative of problems of modern living. These social conditions seriously erode and undermine the physical and mental well-being of communities as well as individuals. For example, people living in unhygienic conditions in informal settlements where there is no sewerage system are more susceptible to contracting tuberculosis (TB).
There is a growing concern about the increase in mental health problems and disorders. In 2010, it was estimated that mental and behavioural disorders accounted for 7.4 per cent of the global burden of disease, with major depressive disorder accounting for 34.1 per cent of this (National Institute of Mental Health, n.d). Adverse social factors such as poverty, unemployment, escalating HIV/ AIDS incidence, crime, violence, and alcohol and substance abuse affect all sections of South African society. These conditions have grave implications for mental well-being. Globally, one in five people (children, adolescents and adults) are estimated to suffer from a diagnosable mental disorder that affects their social functioning (Kleintjes, Lund, Flisher et al., 2010). Moreover, general practitioners estimate that 25 per cent of all their patients are ill due to psychological distress rather than biological causes. Adolescents in particular are regarded as a high-risk group. According to the World Health Organization (2013), in 2012 suicide was the second highest cause of death amongst 15—29 year-olds. In addition, 75 per cent of global suicides happened in low- or middle-income countries.
The awareness of the interaction between psychological, social and biological factors in health has brought about a shift from a predominantly biomedical model to a more inclusive and comprehensive bio-psychosocial model of health and disease.
The biomedical approach
In South Africa, health services have been strongly influenced by the traditional biomedical model that primarily focuses on the treatment of physical signs and symptoms of mental illness. This approach regards mental health as being secondary or subordinate to physical health, resulting in mental health being seen as less important, having a low priority status, and hence receiving less attention and being allocated fewer resources. The dominance of the biomedical approach, with its partitioning of mental health and physical health, has separated and fragmented the provision of health services. Consequently, many mental and behavioural disorders have been neglected, have gone undetected and/or have been left untreated, resulting in much misery and waste of human potential.
Cowen (2000) contends that the traditional biomedical definition of mental health (and its main focus on dysfunction, biological causative factors of disease, and the remedial treatment of diagnosed illnesses) has narrowed and restricted the focus of traditional psychology. This has been reflected in psychology’s limited focus on individual behaviour and the intrapsychic facets and processes of behaviour, and the assessment, diagnosis and treatment of pathology and dysfunctional behaviour. This has, in turn, led to the neglect of other equally important factors, such as the individual’s environment, social context, relationships and the interaction between these.
The bio-psychosocial approach
In contrast to the dualistic mind/body separation of the biomedical model, the bio-psychosocial approach calls for a more holistic and integrated view of well-being. The bio-psychosocial model of health acknowledges that physical and mental health cannot be separated, maintaining that an individual’s physical, behavioural and social contexts are interrelated and integral to mental health. Hence its broader focus is on the holistic treatment of individuals, including rehabilitation, prevention of mental illness, and the promotion and enhancement of mental health (Albee, 1982; Cowen, 1994, 1996, 2000; Prilleltensky & Nelson, 2002). Developments in neuroscience, genetics and the behavioural and social sciences have advanced our understanding of mental health and disorders. Recent scientific evidence indicates that the interaction between biological, psychological and social factors is a determining factor in mental and behavioural disorders (World Health Organization, n.d.).
•Individual health and prosperity are closely tied to community health and well-being.
•Modern life generates stressors which erode individual and community health, both physical and mental.
•Adverse social factors also have a negative impact in terms of psychological distress and mental disorders.
•The traditional biomedical approach to health focuses primarily on the treatment of physical signs and symptoms of mental illness. Mental health has had a lower priority status; as a result, health services have been fragmented and mental disorders neglected. In addition, individual and intrapsychic factors have been emphasised at the expense of environmental factors.
•The bio-psychosocial approach is more holistic and integrated. This approach understands that the interaction of biological, psychological and social factors influence mental and behavioural disorders.
•There is a need to extend mental health services beyond the individual to the community.
26.1PREVENTION IS A NEGLECTED FOCUS
Research indicates that most emotional or behavioural problems have their origins in negative social environments where, for example, poverty, violence, crime, abuse and social injustice abound (World Health Organization, n.d.). Various theorists have shown that early exposure to negative social contexts could drastically limit optimal social development and result in later adult pathology. But, despite the knowledge gained from decades of prevention research and the positive benefits of preventative interventions, commitment to the science and the practice of interventions has been limited. The status quo has largely been maintained with traditional diagnostic systems, therapeutic approaches and training methods that perpetuate a victim-blaming stance and adhere to the biomedical model for conceptualising the consequences of social problems. For example, the sequelae of all forms of violence against women and children in South Africa hold grave implications for the mental health of this society.
Traditional individual curative ways of rendering services to such victims of violence, notwithstanding their positive benefits for patients, could be regarded as ’band-aid’ therapy. The treatment is merely focused on the symptoms of the problems and does not address their root causes. Such interventions would also not necessarily reduce the incidence of violence against other women and children in the broader population.
Prevention science advocates addressing such problems by rendering services as well as harnessing efforts to combat the development of such psychosocial issues. The focus of primary prevention would be to address the core of the problem by confronting the entrenched cultural forces, such as patriarchy and gender inequality, that perpetuate male dominance over women and children. Direct preventative interventions would include improving nutrition and housing, as well as access to education, reducing poverty and enhancing community networks (World Health Organization, 2004). Secondary and tertiary prevention would render services to both the victims of violence as well as rehabilitation programmes for perpetrators. Violence-prevention interventions should be multilevel and across disciplines. For example, the family, school, traditional leaders, church, media, clinics, hospitals, government and places of work should all be involved. The entire population should be targeted, not merely the victims and perpetrators of violence.
Similarly, the psychological, social and economic implications of the HIV/AIDS pandemic are critical for the development of South Africa. The particular vulnerability of young women to infection and death from AIDS-related illnesses is also indicative of the broader, systemic social inequalities within South African society. Individual interventions to stem the escalating levels of the HIV/AIDS pandemic in South Africa have not met with much success as Western theoretical models of the disease have been applied. These theories emphasise individual personal processes, ignoring the complex interplay of social, economic, cultural and political factors that operate in developing societies. In order to change high-risk sexual behaviour and attempt to make some impact on the prevention of the spread of this pandemic, the interaction between the different systems within a society need to be considered.
In a developing country such as South Africa, with, on the one hand, historical inequities, backlogs and limited resources, and, on the other hand, the vast need for prevention and mental health services, the challenge is to apply resources optimally for the benefit of all. It is important to shift from applying resources to small-scale modes of treatment to interventions that can use limited resources more broadly for the prevention of mental health problems. Examples of specific programmes established in the US include the following (Trust for America’s Health, 2009):
•In Alabama in 2010, a community action plan aimed to reduce barriers preventing African American women receiving screening for breast and cervical cancer. Two years later, 14 per cent more women had had a mammogram, while 11 per cent more had had a Pap test.
•In West Virginia, a state with a very high smoking rate, tobacco control programmes have resulted in most restaurants being smoke free, while the WV Tobacco Quitline has reported a 32 per cent rate for stopping smoking.
•In Washington State, school districts laid down a ’staff walking challenge’ in which staff formed teams to compete to log the most physical activity. This led to a 60 per cent increase in people taking moderate exercise four or more days per week.
This also raises issues at another level, namely, the nature and relevance of professional training in psychology and the location of mental health professionals within the broader society. Clearly, the training of mental health professionals in a developing country should not be geared for private practice, with a focus on individual-oriented treatment paradigms. Training programmes need to prepare mental health professionals for work in the broader community, with a focus on prevention science and issues of social justice.
Few people would argue against the folk wisdom that prevention is better than cure, yet psychology as a profession continues to apply its energies to remediation. However, it makes better economic sense to apply resources to prevent mental health problems from developing than the costly expense, both human and material, of treating them. Prevention should not merely address the symptoms, but should confront the deep-seated structural inequalities embedded within a society that give rise to the development of mental health problems.
As early as 1951, Kurt Lewin advocated that behaviour needed to be thought of as a function of the interaction between the person and environment (B = f(P × E)). However, many mental health practitioners adhere to a far more limited formula: B = f(P) — that is, behaviour is the function of the person. As a result, many professional programmes continue to perpetuate the individualistic-remedial-intrapsychic approach to psychology even though the communities’ needs for mental health services far exceed this limited modality (Lewis, Lewis, Daniels & D’Andrea, 2003).
Defining mental health
Mental health and its more recent reformulations, wellness or well-being, have diverse meanings in different social contexts. There is no single definition that fully encapsulates the essence of these concepts. As far back as 1948, the World Health Organization defined health as a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.
Cowen (1994) contends that wellness and sickness are culturally determined constructs and, given the diversity of cultural values, seeking a uniformly acceptable definition for these is a complex and illusory process. He contends that wellness and pathology (sickness) should be seen as the two anchoring ends of a hypothetical continuum, where wellness is the positive end, representing an ideal to continually strive towards. It should be of prime concern, not only attended to when it breaks down (Cowen, 1996, 2000).
Cowen also argues that ’wellness … is defined by the presence of positive marker characteristics that come about as a result of chance combinations of organismic, familial, community and societal elements’ (Cowen, 1996, p. 247). These positive markers are behavioural and psychological. Behavioural markers refer to actions such as the ability to work productively and form sound interpersonal relationships. Psychological markers include processes such as having a sense of purpose and belonging, self-efficacy and control over our fate (Cowen, 1994).
Dimensions of mental health
In 1981, the World Health Organization emphasised the social dimensions of mental health and the importance of social environments when it stated the following:
Mental health is the capacity of the individual, the group and the environment to interact with one another in ways that promote subjective well-being, the optimal development and use of mental abilities (cognitive, affective and relational), the achievement of individual and collective goals consistent with justice and the attainment and preservation of conditions of fundamental equality (World Health Organization, 2000a, p. 11).
This statement and related research show that mental health:
•goes beyond the biological and the individual
•is culturally constructed and rooted in subjective value judgements
•is complex and multidimensional, for as one progresses from one life stage to the next, there are a number of systems that can impact on wellness (Cowen, 2000)
•is facilitated or undermined by a number of interrelated factors operating on different levels (e.g. a child’s well-being is dependent on the family, school, peer groups)
•has a social dimension and is influenced by non-psychological factors (e.g. having a job, housing, access to sanitation and water) (World Health Organization, n.d.)
•is facilitated by conditions of social justice and equality (Prilleltensky & Nelson, 2002).
Thus, if an unemployed pregnant mother is malnourished or vulnerable to substance or physical abuse, such negative stressors will impact on the viability of the growing foetus, affecting its physical and cognitive development and ultimately the mental health of both the child and mother. Thus there are multiple systems involved in the mental well-being of an individual, some having an impact even before birth.
The interdependence of the dimensions of mental health
Figure 26.1 illustrates the hierarchical structure and ecological interdependence of mental health or well-being (Prilleltensky & Nelson, 2002). Any individual is embedded in several interacting social systems such as families, neighbourhoods, communities and broader society. Each of these layers of society exerts a particular influence on the individual, some directly and others indirectly, some positively and others negatively. Therefore, the mental health and well-being of individuals are shaped by social conditions that are often beyond their control. Any individual’s personal well-being is dependent on the well-being of their immediate family, which in turn depends on external community conditions and societal conditions.
Figure 26.1 The social interdependence of mental health
Within this ecological model of development, Prilleltensky and Nelson (2002) describe three domains of well-being (integrating both physical and mental health): personal well-being, relational well-being and collective well-being. These domains are interdependent, with the quality of well-being in one domain likely to impact on the quality of well-being in the other domains. Well-being itself is attained when there is a ’simultaneous and balanced satisfaction of personal, relational and collective needs’ (Prilleltensky & Nelson, 2002, p. 8).
Personal well-being is fostered when the necessary conditions for the protection of an individual’s physical and emotional health are ensured, and where self-determination and personal growth are promoted. Interventions in this domain are aimed at empowerment, giving individuals mastery, control, a voice and choice over aspects of their emotional and physical well-being. Counselling and psychotherapy are interventions fostering personal well-being.
Relational well-being focuses on the promotion of respect and appreciation for human diversity and for collaboration and democratic participation. The needs addressed at this level include integrity, acceptance, dignity and self-respect. Interventions in this domain encourage people to participate in decision-making processes and to assume mutual responsibility.
26.2INDIVIDUAL WELLNESS: A CONTEXTUAL UNDERSTANDING
Source: Myers, Sweeney and Witmer (2000)
Myers et al. (2000) present an interesting integrated holistic model of wellness and prevention over a life span. Their model presents individual characteristics necessary for optimal health. The wheel of wellness depicts how different facets of an individual’s life and wellness in one area, whether positive or negative, affect other areas. Healthy functioning also occurs on a developmental continuum. Behaviour at one stage of life impacts on development and functioning at a later stage. Therefore prevention of sickness and early interventions into sickness are seen to enhance social functioning.
In the pursuit of wellness, an individual engages in interrelated life tasks. The first life task and the core of wellness is spirituality, as reflected by one’s moral values and the pursuit of the meaning of life. This is followed by the life tasks of self-direction, work, leisure, friendship and love. These life tasks interact dynamically with life forces both within and outside the individual. External life forces refer to societal institutions such as the family, the community, and religious, educational, governmental and economic systems. Further, both natural and human global events, such as earthquakes, floods, famine, wars, poverty, unemployment, economic decline, exploitation, injustice and terrorism, have an impact on the life tasks and life forces.
Figure 26.2 The wheel of wellness
Collective well-being is fostered when vital community structures that facilitate the pursuit of personal and communal goals are established. This provides a sense of community, cohesion and formal support. Equally important for collective well-being is the attainment of social justice, ensuring fair and equitable allocation of bargaining powers, obligations and resources in society. These resources include enabling institutions and infrastructure. It follows, then, that well-being cannot be conceptualised in a vacuum or be reduced to individual responsibility:
Personal needs such as health, self-determination, and opportunity for growth are tied to the satisfaction of collective needs such as adequate health care, access to safe water, fair and equitable allocation of resources and economic equality (Prilleltensky & Nelson, 2002, p. 12).
When health-promoting factors are available on all levels, a positive synergistic effect is likely to ensue. However, when neglect, injustice and exploitation combine with a lack of resources, then social fragmentation, ill-health, suffering and oppression will emerge.
Figure 26.3 Having healthy, stable early attachments with parents and primary caregivers is thought to serve as a protective factor against mental illness
•Mental health, wellness or well-being have diverse meanings in different social contexts.
•According to the WHO, health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.
•Wellness and sickness are culturally determined constructs which can be seen as two ends of a continuum.
•Wellness is defined by the presence of positive behavioural and psychological markers.
•Mental health, wellness or well-being have diverse meanings in different social contexts.
•According to the WHO, health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.
•Wellness and sickness are culturally determined constructs which can be seen as two ends of a continuum.
•Wellness is defined by the presence of positive behavioural and psychological markers.
•There are significant social dimensions to mental health. Mental health involves subjective value judgements. It is influenced by life stage, as well as non-psychological factors including access to resources, social justice and equality.
•Mental well-being depends on the synergistic interaction between the individual and their surrounding social systems (families, neighbourhoods, communities and broader society).
•Personal well-being develops when the individual’s physical and emotional health are fostered.
•Relational well-being depends on respect and appreciation for human diversity and for collaboration and democratic participation.
•Collective well-being depends on community structures that provide a sense of community, cohesion, formal support and social justice.
Protective factors and risk factors
As described in the previous section, the mental health of communities is affected by social, economic, political and individual factors. The relationship between these factors impacts on psychological well-being, particularly on the nature, intensity and duration of mental health problems and disorders. Risk and protective factors can exist at all levels with influences operating at the individual, the interpersonal, community and structural societal levels (Petersen, 2010).
Mental and behavioural disorders are formal categories as indicated by the DSM-5 and the International Statistical Classification of Diseases and Related Health Problems (ICD-10), and refer to conditions that are characterised by alterations in thinking, mood or behaviour in vulnerable individuals (American Psychiatric Association, 2014; World Health Organization, 2007a). Mental health problems refer to those psychological and social stresses that the majority of people experience, but which lack the intensity and duration to be classified as a mental disorder. Some individuals who are predisposed may develop mental disorders, triggered by psychosocial stressors or biological imbalances, whereas the majority are able to cope, to a lesser or greater degree, owing to protective factors. These protective factors could reside within the individual or in the family or community.
26.3FATAL INJURIES: THE NEED FOR PREVENTION AND INTERVENTION
Source: Donson (2009)
Information was collected as part of the National Injury Mortality Surveillance System (NIMSS) developed by the Medical Research Council and the Institute for Social and Health Sciences of UNISA. This information was collected from 62 medico-legal laboratories in seven provinces in South Africa during 2008 to determine the who, what, when, where and how of fatal injuries.
A total of 31 117 fatal injuries were recorded by NIMSS, representing 39 to 52 per cent of all injury deaths in the country. Of these, 78.4 per cent were male and 21.6 per cent were female. The majority of the deaths from violence involved young adults (44 per cent) between the ages of 15 to 39 years. Homicide was the major cause of death, accounting for 31.5 per cent of all deaths. Transport-related deaths accounted for 29.4 per cent, suicide for 10 per cent and other unintentional or accidental injuries for 17.5 per cent. Sharp objects (13.6 per cent) were the leading cause of violent death, while firearms accounted for 10.8 per cent of all cases. For children between 1 and 4 years of age, sudden infant death syndrome was the major cause of death, and for children between the ages of 5 and 14 years, pedestrian injuries were the major cause of death. Hanging accounted for 46.2 per cent of suicides, poisoning for 17 per cent and firearms for 13.5 per cent, with over 4 male suicides for every female suicide.
Fatal injuries, especially resulting from violence and transport accidents, constitute priority threats to South African citizens. The NIMSS data lends itself to the formulation of injury prevention interventions at national and community levels. Interventions within a public health model can be designed to address some of the risk factors identified for potential victim groups.
Protective factors refer to those processes that promote resilience within an individual and serve as buffers against the likelihood of developing mental health problems. Petersen (2010) suggests that protective factors are multifaceted, and include genetic aspects, as well as temperament, physical health, interpersonal factors and broader societal aspects like economic policy. Cowen (1994, p. 158) highlights five necessary strands that enhance mental health and serve as protective factors against mental illness:
•having and forming healthy and stable early attachments with parents or the primary caregiver(s)
•developing age- and ability-appropriate cognitive and interpersonal competencies
•exposure to positive settings and social environments that enhance mental health
•creating empowering conditions that provide people with opportunities to be in control of their lives and enhance decision making
•developing the ability to deal effectively with the major stressors of life.
Risk factors refer to all those characteristics or variables (biological, psychological or social) that are associated with the vulnerability of an individual to develop negative outcomes and the likelihood that these outcomes will occur (Mash & Wolfe, 2002). However, it should be noted that risk factors are not absolutes; an individual’s engagement with risk processes could result in adaptive coping strategies to overcome the risks and these processes could further serve as protective mechanisms (Rutter, 1990). Petersen (2010) notes that by reducing risk and enhancing protective factors, impairment in children can be limited and health outcomes can be strengthened in adults of all ages.
Biological risk factors refer to variables such as age, gender, organic deficits and genetics. Studies of extended multigenerational families indicate that most of the common severe mental and behavioural disorders have a strong genetic component (World Health Organization, n.d.).
Psychological factors refer to intrapersonal factors such as poor or ineffective coping strategies in dealing with stressful life events. These could result in certain kinds of mental and behavioural disorders such as depression or anxiety. Ainsworth and Bowlby (in Cowen, 1994) have indicated the importance of secure attachment from birth to adolescence for sound development and mental well-being. The chapters in Part 2 describe in detail how the absence of such nurturing relationships may pose a threat to psychological well-being and restrict the foundations for future development (Cowen, 1994).
Social factors include interpersonal, group, community and societal factors such as the escalation of HIV/AIDS, urbanisation, rapid social and technological change, racism, oppression, escalating levels of crime and violence, gender violence and the lower status of women, poverty and socio-economic status. These factors are integrally linked to well-being and could impact negatively on mental health (World Health Organization, n.d.) leading to a wide range of social and psychological consequences.
The World Health Organization (2000a) contends that, given the multiple roles they play in society, women are at greater risk of developing mental and behavioural disorders. Despite being an integral part of the labour force and being the prime source of income for their families, their status remains low worldwide. Research indicates that people from low socio-economic status circumstances have a higher risk for common mental health disorders (Patel, Araya, De Lima, Ludermir & Todd, 1999). Further, violence against women has escalated and has become a public health issue because of the devastating consequences for women’s mental and physical well-being (Jewkes, 2002). Thus, the mental health and well-being of women is linked to their status in society and has a direct impact on human well-being and the prospects of future generations (World Health Organization, 2000a).
•The mental health of communities is affected by social, economic, political and individual factors.
•Risk and protective factors can exist at all levels (individual, interpersonal, community and structural).
•The DSM-5 and ICD-10 place mental and behavioural disorders into formal categories; most people experience mental health problems at some stage in their lives, but these are less intense and of shorter duration.
•Some people are more vulnerable than others to mental health disorder; this often depends on protective and risk factors.
•Protective factors promote resilience and serve as buffers against the likelihood of developing mental health problems.
•Risk factors are the biological, psychological or social variables that increase the vulnerability of an individual to develop negative outcomes; some risk factors result in adaptive coping strategies and thus serve as protective mechanisms.
•Women are at greater risk of developing mental and behavioural disorders due to their low status in society and associated violence against them.
Mental health services in South Africa
In the past, mental health provision in South Africa was marked by racial segregation, fragmentation and duplication. It has been described as inadequate, inaccessible (particularly for rural communities), inappropriate, discriminatory, and based largely on institutional custodial care (Lazarus, 1988; Naidoo, 2000; Petersen et al., 2009). Although access to health care has improved, the quality of health care has fallen, compounded by significant public health challenges like HIV/AIDS and TB (Health care in South Africa, n.d.).
The present inequalities of mental health provision still reflect broader class, race, gender and urban—rural inequalities (Sukeri & Emsley, 2014). Historical legacies are exacerbated by the sparse distribution of mental health personnel such as psychiatrists, psychologists and social workers within the public sector (Sukeri & Emsley, 2014). In South Africa, the ratio of psychiatrists to patients is 1:130 500 whereas the equivalent ratio in developed countries is 1:14 000. The ratio of psychologists to patients is equally limited. In the Eastern Cape, a population of 6 527 747 is served by 28 psychologists and 14 psychiatrists (Sukeri & Emsley, 2014).
Most mental health professionals still work in private practice, while those working in the public sector are unevenly distributed across the provinces. Mpumalanga and the Northern Province are particularly compromised in terms of mental health workers (Pillay & Petersen, 1996; Pillay, Freeman & Foster, 1997). It is clear that the mental health needs of black South Africans and disadvantaged communities have largely been neglected (Naidoo, Shabalala & Bawa, 2003).
Furthermore, health intervention in South Africa has traditionally been predicated on the biomedical model. Therefore even mental health care was predominantly hospital based with the emphasis on curative relief of symptoms and medication as treatment (Sukeri & Emsley, 2014).
Mental health personnel were trained to deal with problems experienced in developed countries, rather than on those that were characteristic of a developing country (Kalisky, 1998). This set of factors rendered mental health services in South Africa largely inappropriate to the majority of South Africans, catering mainly for the privileged minority. However, much has improved with regard to training, especially in terms of trainee demographics and programme content (Pillay & Kramers-Olen, 2014), although there are still criticisms that professional psychology training in South Africa needs greater relevance to the South African context (Nair, 2008).
The restructuring of mental health provision in post-apartheid South Africa has therefore not occurred in a vacuum, nor from a level foundation. To redress the inequities of the past, restructuring the provision of mental health services required a two-pronged approach, influencing both policy and practice. First, a new health strategy needed to be drafted, reconciling the neglect and lessons of the past with current needs and available resources. Second, new training strategies to deliver the proposed new health system were needed.
When the new policy for restructuring health services in South Africa was drafted, a broad-based approach rooted in primary health care and driven by a human rights approach was adopted by the National Department of Health in its Health Sector Strategic Framework (1999—2004) (Department of Health, 2002). The intention was to provide access to health care (for both physical and mental health) for all South Africans at a community level. Mental health has also been defined more broadly to include psychological health and well-being as well as mental illness.
However, Pillay et al. (1997) indicates that this has not yet resulted in any major shifts in resources, or additions to the amounts allocated for mental health services. Further, there is a concern that the added integration of mental health services into the already overburdened and under-funded primary health care system could further contribute to the lack of detection and neglect of mental health problems. Also, primary health care is essentially biomedically oriented and could perpetuate the medicalisation of social problems and hence the marginalisation of mental health (Nell, 1994).
An ongoing problem in health provision in South Africa is the ’two-level’ system incorporating an underfunded public health system with a private health sector which caters for middle- and high-income earners. In response to this, the South African government is working to implement a national health insurance scheme, while also trying to improve services and make health care affordable to all South Africans (Health care in South Africa, n.d.)
Significantly, the watchdog of the health professions, the South African Medical and Dental Council, was rationalised and renamed the Health Professions Council of South Africa. This gave increased independence and equity for professions such as psychology, occupational therapy and physiotherapy, which were formerly accorded a lower professional status in relation to medical disciplines by being labelled supplementary health professions. Several of the health professions have made adjustments to their training requirements and have instituted compulsory community service before graduates will be allowed to register with their respective professional boards.
The primary health care approach
The Health Sector Strategic Framework adopted by the Department of Health (2002) adheres to a primary health care approach. The World Health Organization and United Nations’ Children’s Fund officially adopted a formal definition of primary health care in 1978 at a conference in Alma Ata in the Soviet Union. According to the Alma Ata Declaration (World Health Organization, 2000b), the primary health care system of a country should be based on:
•accessibility and acceptability of health services
•priority given to those in need
•the presence of an integrated, functional and supportive referral system
•levels of community participation in the planning and implementation of health care.
The primary health care approach embraces the concepts of equity, accessibility and appropriateness of services for the communities in which they are rendered, focusing on the prevention and promotion of well-being for individuals and families within the community context. Interdisciplinary and intersectoral collaboration is encouraged, requiring health professionals to work together with other health workers, agencies and departments outside of the health sector when appropriate. The government’s public health strategic framework strongly motivates for the principles of primary health care to be implemented via the public health service.
Mental health structures within the public health service
In the Health Sector Strategic Framework (Department of Health, 2002), the public health service is based on a district health system that operates on a three-tier system. The primary tier consists of community-based clinics that are the primary site of health services (including mental health services). These primary health care clinics are usually staffed by nurses. On a secondary level, the community is incorporated into a district such as the Boland, which has one district hospital. The third tier consists of a tertiary academic hospital, like Lentegeur Psychiatric Hospital in the Western Cape. When mental health problems become too severe to be dealt with at a primary care level, primary care nurses usually refer patients to subsequent tiers in the health system. A cyclical referral process is envisaged whereby individuals who have been assisted at a tertiary level, once stabilised, are discharged into their communities for ongoing maintenance and support (Department of Health, 2002).
•South Africa has a long history of unequal and fragmented provision of health care, based largely on a biomedical approach.
•The country faces major health care challenges, including the burden of disease and limited physical and human resources.
•In particular, the mental health needs of black South Africans and disadvantaged communities have been neglected.
•In restructuring health care services, the government has paid attention to new strategies for resource use and for training; these are rooted in a primary health care approach. However, mental health care remains problematic.
•The status and independence of psychology as a profession were enhanced by the formation of the Health Professions Council of South Africa.
•The primary health care approach is based on the Alma Ata Declaration; it emphasises equity, accessibility and appropriateness of services for the communities in which they are rendered and focuses on prevention of disease and promotion of well-being.
•The public health service is based on a district health system that operates on a three-tier system comprising health care clinics (primary level), district hospitals (secondary level) and academic hospitals (tertiary level).
Community mental health
Community mental health is practised largely at the primary care level in communities within the public health system, and incorporates both curative and preventive interventions. Community mental health can be conceptualised as a multifaceted approach. In this approach, intervention strategies extend beyond traditional methods, that focused exclusively on the individual, to include interventions such as life skills training and advocacy, which are aimed at preventing mental health problems and enhancing psychological wellness. Not only are individuals targeted for intervention but also groups, organisations and even the whole community in a given geographical location. These strategies draw on local resources and strengths to facilitate capacity building and empowerment within communities. These communities are helped to implement the programmes that they have decided they need. These initiatives are therefore not only geared to alleviate mental illness but also to promote mental health, to prevent mental health problems and to facilitate broader systemic change. Caplan (1964) differentiates between primary, secondary and tertiary levels of intervention:
•Primary prevention ensures that people without psychiatric symptoms remain healthy. Interventions at this level are targeted at improving support for individuals, either in terms of resources or coping skills, and are intentionally focused on promoting well-being. An example of such an intervention would be the implementation of life skills programmes for all learners in schools.
•Secondary prevention assists individuals who are vulnerable or at risk of developing mental health difficulties to remain symptom free. Early intervention is essential in this context. Early school programmes that concentrate on assessment and identification of behavioural and cognitive difficulties, with the intention to intervene, typically fall into this category.
•Tertiary prevention aims to ensure a positive quality of life for individuals who already suffer from a mental disorder or condition. Psychosocial rehabilitation of psychiatric patients is a good example of tertiary prevention. In this regard, psychiatric patients typically receive rehabilitation with regard to employment opportunities, living circumstances and personal care. While curative and preventive interventions have been viewed as mutually exclusive, theorists and practitioners are increasingly advocating that these interventions should take place concurrently and complement each other (Naidoo & Van Wyk, 2003; Scileppi, Teed & Torres, 2000).
Figure 26.4 The mental health intervention continuum
A model of community intervention
Lewis et al. (2003, p. 31) propose a useful way of conceptualising mental health service delivery in a community that highlights both the multiple levels of intervention and the expanded roles envisaged for psychologists working in communities.
This model differentiates between direct and indirect services, and between community and patient services, yielding four distinct components that represent different service modalities (see Table 26.1):
•Direct community services. These services provide educational experiences aimed at the community as a whole and are preventive in their intention and objective. The mental health practitioner is typically involved in preventive psycho-education initiatives such as implementing HIV life skills programmes.
•Direct patient services. These services are directed at individuals who have actively sought help and have been identified as experiencing problems or who are at risk of developing future mental health problems. Examples of specific services used in this component include counselling and outreach to vulnerable individuals in the community. This component of intervention is usually implemented within traditional modes of psychological intervention.
•Indirect community services. These services and interventions involve efforts intentionally designed to make the social environment more responsive to community needs. In promoting these types of constructive changes, the mental health practitioner collaborates with key community role players in targeted areas to cultivate positive systemic changes, typically by influencing public policy. Initiatives to modify or change the social environment that contributes to poor mental and physical health are central to this role. For example, psychologists can engage with community groups to argue for legislation assisting young girls to return to school after a teenage pregnancy. Their increased levels of education may increase their employability, which in turn will contribute to their psychological wellness.
•Indirect patient services. Services and interventions in this component include those environmental interventions that are aimed at meeting the special needs of people presenting with mental-health disorders or who may be at risk. Services are primarily aimed at creating new helping networks by providing consultation and patient advocacy assistance to people and agencies within the areas where patients live. By facilitating patients’ use of their own personal power as well as resources and networks within their community, the mental-health practitioner assists patients in helping themselves. A typical example of an intervention within this component is the provision of support groups to overburdened primary-health-care staff suffering from burnout. By providing this intervention, psychologists indirectly assist the nurses’ patients, and are therefore able to provide an improved quality of service to the community (Lewis et al., 2003:49).
Table 26.1 Model of intervention in communities
Influencing public policy
In integrating these four components into a unified complementary and interdependent framework, mental health practitioners can begin to conceptualise the types of interventions appropriate for the purpose in mind. Such a comprehensive helping framework will necessarily embrace both ameliorative (healing) and transformative (change-promoting) agendas. This framework should include a range of interventions ranging from curative and remedial services to programmes predominantly focusing on prevention, health promotion and social change. It should also provide a continuum of care where values such as empowerment, participation and social justice can be incorporated into a primary health care approach (see Figure 26.4).
•Community mental health is practised largely at the primary care level in communities within the public health system, and incorporates both curative and preventive interventions.
•Interventions are aimed at individuals, groups, organisations and even the whole community.
•Intervention can be at primary, secondary or tertiary level:
”Primary prevention aims to keep people without psychiatric symptoms healthy.
”Secondary prevention targets individuals who are at risk of developing mental health difficulties, helping to keep them symptom free.
”Tertiary prevention aims to ensure a positive quality of life for individuals who already suffer from a mental disorder or condition.
•Lewis et al. (2003, p. 31) developed a model of community intervention which differentiates between direct and indirect services, and between community and patient services:
”Direct community services involve prevention interventions aimed at the community as a whole.
”Direct patient services are for individuals who have sought help and have been identified as experiencing problems or who are at risk of developing future mental health problems.
”Indirect community services involve efforts to make the social environment more responsive to community needs.
”Indirect patient services aim to meet the special needs of people presenting with mental health disorders or who may be at risk.
”This comprehensive framework for intervention assists in developing appropriate curative and remedial interventions.
26.4EFFECTIVENESS OF INTERVENTION PROGRAMMES
There is a clear need for mental health prevention interventions, especially those aimed at children and young people (Albino & Berry, 2013). It is, however, essential to evaluate prevention programmes to ensure that they are achieving their goals in a cost-effective manner. Patel et al. (2007) noted that interventions to prevent mental disorders had been widely found to be effective. However, of over 11 000 trials identified by these authors, fewer than one per cent involved low-income countries and only 10 per cent involved low- and middle-income countries. Thus, Patel et al. (2007) focused their study on low- and middle-income countries. They found that ’some trials of interventions for prevention of depression and developmental delays in low-income and middle-income countries show some beneficial effects’ (Patel et al., 2007, p. 991). However, there was insufficient evidence for interventions in the wake of disasters and for developmental disabilities. There is thus a need for more research in these areas. Notwithstanding these findings, Patel et al. (2007) argue that policymakers should scale up prevention interventions that have proven effective as well as cost effective.
Durlak and DuPre (2008) note that designing effective interventions is only useful if these are transferred successfully into real-world settings and effectively maintained. Thus, these authors investigated the role of implementation factors on programme effectiveness. Durlak and DuPre (2008) analysed 542 reports of prevention and health promotion interventions and found strong support for the idea that the level of implementation affects programme outcomes. They identified ’at least 23 contextual factors that influence implementation’ (Durlak & DuPre, 2008, p. 327). These factors related to the communities and providers involved, the functioning of the programme delivery system, and the training and technical support provided to the programme. Durlak and DuPre (2008) concluded that it is essential for evaluations of programmes to collect data concerning the implementation factors.
Since 1994, South Africa has adopted a health system that focuses predominantly on primary health care, creating new challenges to the health professions for the delivery of health services. Seen from the perspective of the country’s 1996 constitution, the provision for optimum mental health needs is considered to be the right of all individuals and communities in South Africa. How to foster and achieve this basic right is a challenge for government, mental health professionals, community role players and the private sector, who should all form collaborative partnerships.
behavioural markers: the marker characteristics that come about as a result of chance combinations of organismic, familial, community and societal elements, and refer to actions such as the ability to work productively and form sound interpersonal relationships
biomedical model: a model of health care that primarily focuses on the treatment of physical signs and symptoms of mental illness
bio-psychosocial approach: a model of health care that calls for a more holistic and integrated view of well-being
collective well-being: within an ecological model of development, a domain of well-being that is fostered when community structures facilitate the pursuit of personal and communal goals, providing a sense of community, cohesion and formal support
direct community services: a service modality that provides educational experiences aimed at the community as a whole, which are preventive in their intention
direct patient services: a service modality that is directed at individuals who have actively sought help, and have been identified as experiencing problems or who are at risk of developing future mental health problems
indirect community services: a service modality that involves efforts intentionally designed to make the social environment more responsive to community needs
indirect patient services: a service modality that includes those environmental interventions that are aimed at meeting the special needs of people presenting with mental health disorders or who may be at risk
personal well-being: within an ecological model of development, a domain of well-being that is fostered when the necessary conditions for the protection of an individual’s physical and emotional health are ensured, and when self-determination and personal growth are promoted
primary health care: an approach to health care that embraces the concepts of equity, accessibility and appropriateness of services for the communities in which they are rendered, focusing on the prevention and promotion of well-being for individuals and families within the community context
primary prevention: a level of intervention that ensures that people without psychiatric symptoms remain mentally healthy
protective factors: those processes that promote resilience within an individual and serve as buffers against the likelihood of developing mental health problems
psychological markers: the marker characteristics that come about as a result of chance combinations of organismic, familial, community and societal elements, and which include processes such as having a sense of purpose and belonging, self-efficacy and control over one’s fate
relational well-being: within an ecological model of development, a domain of well-being that focuses on the promotion of respect and appreciation for human diversity and for collaboration and democratic participation
risk factors: those characteristics or variables (biological, psychological or social) that are associated with the vulnerability of an individual to develop negative outcomes and the likelihood that these outcomes will occur
secondary prevention: a level of intervention that assists individuals who are vulnerable or at risk of developing mental health difficulties to remain symptom free
social factors: those interpersonal, group, community and societal factors that could impact on mental health
tertiary prevention: a level of intervention that aims to ensure a positive quality of life for individuals who already suffer from a mental disorder or condition
Multiple choice questions
1.Which of the following statements describe(s) the biomedical model?
a)It focuses on biological causation.
b)It stresses remedial treatment.
c)It emphasises diagnoses.
d)All of the above are correct.
2.The separation of mind and body is characteristic of:
a)the holistic view of well-being
b)the bio-psychosocial model
c)community mental health
d)the biomedical model.
3.Which of the following statements is false?
a)The ability to form sound relationships is a positive behavioural marker.
b)Having a sense of self-confidence is an example of a positive psychological marker.
c)Risk factors cannot serve as protective mechanisms for the individual.
d)Protective factors serve to buffer the individual against mental illness.
4.Which one of the following is an example of tertiary intervention?
a)a life skills programme for all Grade 7 learners
b)providing free condoms in public toilets
c)helping discharged psychiatric patients adjust to living in the community
d)referring learners with attention problems for assessment.
5.According to the model proposed by Lewis et al. (2003), which of the following is correct?
a)Individual counselling is an example of an indirect client service.
b)Advocacy is an example of a direct client service.
c)Running an AIDS-awareness programme is an example of a direct community service.
d)Influencing public policy is an example of an indirect client service.
6.Which of the following is NOT emphasised in the Alma Ata Declaration?
a)the presence of an integrated, functional and supportive referral system
b)priority to be given to tertiary intervention
c)accessibility of health services
d)community participation in planning and implementation of health care.
7.In Lewis et al.’s (2003) intervention model, direct community service is most similar in focus to Caplan’s:
d)both b and c are correct.
8.Which of the following statements contradicts Prilleltensky and Nelson’s (2002) notions of wellness?
a)Wellness is attained only when there is the satisfaction of personal needs.
b)Relational wellness is dependent on how social needs are met.
c)Collective wellness is fostered when vital community resources are established.
d)Personal wellness is fostered when self-determination and personal growth are promoted.
9.__________ refer to those processes and characteristics that serve as buffers against mental illness.
10.Lewin’s formula (B = f(P × E)) emphasises:
a)the biomedical model
b)the internal and external determinants of mental health
c)the Cartesian split
d)the need for assessment using the ICD-10.
1.Discuss mental health within an ecological framework, with special reference to those factors that promote and impact negatively on mental health. Provide appropriate examples to elaborate your answer.
2.How would you as a psychology student use the wellness wheel to promote improved mental health among people in your community?
3.Discuss the nature of protective factors and risk factors in your community that could promote or impede mental health. Provide appropriate examples in your response.
4.Discuss a model of community mental health intervention in South Africa with illustrative examples.
5.Critically discuss the primary health care approach as a means of providing mental health services to all South Africans.
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