III: Case Studies of Innovative Practice and Policy
This part presents case studies of innovative practice and policy initiatives that address some of the conceptual and methodological difficulties with GMH. This expands on a view developed in this book that contextually aware practice and innovations are crucial to enhancing mental health services and outcomes. The part builds on critical insights about GMH made in previous parts and represents a purposeful effort to champion practical outcomes stemming from initiatives developed in partnership with local communities. Contributors were invited to develop case studies around themes relevant to the local settings where the interventions were implemented and to draw links between these settings and the discourses and practice of GMH. The chapters help make visible innovative work that has been conducted in diverse settings in Africa, Latin America, the Caribbean, Australasia, and South and Southeast Asia. The case studies provide opportunities to highlight information about the organizational, policy and sociocultural context in which work relevant to GMH is being undertaken; an analysis of what has made these initiatives innovative and the factors that have shaped their impact; and implications that these initiatives have for GMH policy and practice moving forward.
Three papers specifically address the complexities of ‘task-sharing’ within GMH. Prashanth et al. (chapter 34) discuss the role of non-professionals in a primary health care programme working with tribal populations in rural Karnataka state, India. They detail long-term engagement with a local community. Cooper et al.’s (chapter 23) discussion of two maternal mental health projects in Cape Town, South Africa, delves into the complex realities of implementing global recommendations on task shifting/sharing. One way that these projects innovate on global recommendations is through experiential and interactive training provided to mental health workers. The authors conclude that implementing task shifting/sharing requires an engagement with local social complexities. Hall and colleagues (chapter 30) describe the Brain Gain project in Uganda, highlighting the benefits, challenges and transformative potential of a peer support project operating out of Butabika Hospital, Kampala.
Chapters by Ola and Atilola, and Hickling address school mental health programmes in Nigeria and Jamaica, respectively, arguing for creative and locally specific ways of engaging with schools, children and communities. Through a review of the literature on school-based mental health programmes, Ola and Atilola (chapter 24) argue that the absence of such initiatives in Nigeria provides an opportunity for bottom-up creation and integration of these programmes and culturally specific programmes emphasizing resilience and community engagement. Hickling (chapter 29) traces the trajectory of the Dream-A- World Cultural Therapy approach in Jamaica, which addresses academically underachieving and behaviourally dysfunctional primary school children. The project trials innovative cultural therapies that engage with children’s creativity and imagination in impoverished and marginalized communities.
Several chapters address the theme of culturally sensitive research and practice. Discussing the Transcultural Psychosocial Organization Cambodia, Gamble (chapter 22) argues for caution in transposing therapeutic models across contexts and suggests that local concepts of mental health and wellbeing are crucial to developing culturally sensitive services in both the Global South and Global North. Stewart et al. (chapter 31) describe how commit and act, an international NGO in Sierra Leone providing training in acceptance and commitment therapy, adapted their approach to the local context. This involved collaboration with trainees to develop locally relevant metaphors and language, and careful analysis of the local context and existing services and policies.
Keys and Kaiser (chapter 28) explore language and communication, crosscultural measurement of mental illness and the role of structural violence in mental health disparities in Haiti and the Dominican Republic. They argue that effective cross-cultural measurement and communication techniques are important to achieving an equitable GMH.
In a quite different context in New Zealand, Lambrecht (chapter 26) considers how cultural-clinical integration takes place between a client and the therapist in relation to Maori mental health services. The chapter describes Maori models of wellbeing and distress and develops a cultural formulation of a single case. Carey and McDermott (chapter 27) engage in a similar discussion in relation to the health and mental health status of indigenous Australians, which is much worse than that of other Australians. The chapter analyses the historical reasons for this, considering the role of social determinants and highlights the impact of historical trauma on mental health of indigenous Australians.
Two chapters analyse challenges of small-scale community projects and their value for informing GMH practice. Van der Geest (chapter 25) profiles ‘Cuenta Conmigo’ (CC), who organize psycho-education and peer support for people with a psychotic disorder and their families in Nicaragua. The chapter argues that the lives of people with a psychotic disorder can be improved with a minimal investment. Van der Geest highlights the challenges of sustainable funding and evaluation, which limit the ability of such projects to shape GMH agendas. Chatterjee and Dasroy (chapter 35) discuss Ishwar Sankalpa, an organization addressing homelessness and mental health in Kolkata, India. They describe the evolution of the programme, its underlying values and model as well as challenges. For GMH, Ishwar Sankalpa highlights the importance of collaborative work with communities and experts by experience in developing sustainable interventions.
The theme of mental health and development is addressed in two chapters. Underhill et al. (chapter 21) profile the BasicNeeds model for linking mental health and development, which operates in several countries. A central argument is that it is possible to develop an international model that can be applied in different contexts whilst maintaining flexibility to address local particularities. Banerjee and Chowdhury (chapter 32) examine the commercial, governance and local culture factors which shape high levels of self-harm/suicide linked to pesticide consumption in the Sunderban region in India. They argue for psychosocial interventions, international regulation of pesticide companies as part of preventative psychiatry, and new mental health prevention models addressing issues such as gender inequality and domestic violence.
Sarin and Jain (chapter 33) historically contextualize India’s recently released mental health policy. Their analysis reveals how the new policy reflects continuities from the past, whilst breaking from this past by drawing on expertise beyond biomedical psychiatry. The chapter discusses reasons for success and failure in health service delivery and the state’s approach to policy planning.
The chapters in this part touch a wide range of practice areas. A central theme across chapters is the diverse ways in which local initiatives engage or envision themselves engaging with GMH. The approach to engagement ranges from projects that closely interface with the GMH agenda on one hand to very local, grass-roots initiatives on the other hand. The chapters highlight a key challenge of finding an appropriate balance between the particular and the universal in research and practice in GMH.
Mental health is emerging on the development agenda (Mills 2015; Plagerson 2015) and has been included in the sustainable development goals. However, there are major challenges relating to the types of interventions that may be taken up by donor agencies. As the chapters in the part suggest, there is a value for communities in locally developed or validated psychosocial interventions. Such approaches can contribute to effectively addressing the interface between mental health and development. However, the emphasis within GMH on particular forms of ‘evidence’ such as RCTs limits the pool of potential interventions and biases towards those developed in Euro-American contexts. As Adams et al. (2016) argue, there is a need to consider alternative forms of accounting within GH that go beyond RCTs if interventions are to have wider community acceptability and relevance. The chapters in this part are a step in this direction.