Addressing Community Mental Health: A Moving Target?

The classical position assumed in community mental health across low- and high-resource settings foregrounds community of place. In North America, this is driven by the legacy of deinstitutionalisation with group homes, nursing homes, and other neighbourhood settings where patient care often occurs (Knapp et al. 2011). Community case managers often coordinate multiple health and social care services for mental health clients with complex needs, often without equal attention to social challenges such as poverty, unemployment, criminalisation, and violence (Kleinman 1988). Individuals often oscillate between acute hospital settings and incarceration, while many struggle with homelessness or settings that exacerbate experiences of mental distress, rather than resolve them (Weinstein et al. 2013).

In African and other low-income country settings, resource limitations and a lack of mental health policies have limited the availability of community mental health care services. Trials of community-based services in some countries date back to the 1960s and 1970s, where, in line with deinstitutionalisation movements elsewhere, emphasis was placed on treating individuals within community spaces. While many countries continue to over-rely on institutional settings, there has been a shift towards the provision of mental health within primary care on the continent (Hanlon et al. 2010). Current community approaches include a range of interventions, such as integrated primary mental health care, which links mental health services to existing primary care clinics and programmes and is increasingly popular in LMICs (Petersen et al. 2009).

From a pragmatic position, communities bounded by space are an inescapable dimension for health services. Across districts, provinces, or neighbourhoods, health practitioners are allocated based on population levels. As such, attention to communities of ‘place’ in itself is not limiting, as place-driven realities are known to exert boundaries on the possible realities for social outcomes (Howarth, Foster and Dorrer 2004). For example, poverty, violence, and unemployment contribute to mental health outcomes, making the achievement of well-being more or less likely in settings shaped by such factors. Ultimately, it is the prioritisation of community as place over other forms of community that emerges as problematic (Campbell and Cornish 2010).

Increasingly, mental health supports have attempted to engage with broader community issues of culture, power, knowledge, and identity, which are key psychosocial determinants of mental well-being (Keyes 1998; Burgess and Campbell 2014). For example, a 2012 special issue on community mental health in Australia acknowledged the importance of viewing community at the level of space (environmental infrastructure), place (socio-historical dimensions of community), and people (attention to the skills and capabilities of individuals) to the promotion of mental health in low-income communities (Rose and Thompson 2012). Furthermore, community psychology approaches aim to promote justice and social change in communities through attending to the interplay between symbolic (i.e. identity) and structural (i.e. poverty, systems of governance) aspects of community and their related impacts on health within the space of interventions (Nelson and Prilleltensky 2010).

However, current WHO and MGMH discourses driving research and action frameworks for mental health practice tend to emphasise community engagement in relation to the pragmatics of bio-psychosocial services, assuming community homogeneity in the process of prioritising spatial dimensions above other issues (Campbell and Burgess 2012; Patel and Prince 2010; Summerfield 2008). For example, a recent study exploring the foundations for integrated mental health care in five low-income countries (Hanlon et al. 2014) asserts the importance of ‘community’ interventions such as adherence support, screening, and community-based psychosocial prevention. While the authors also reference the importance of multi-sectorial collaboration to tackle broader social issues such as housing, this is linked to individual plans for recovery rather than attention to tackling wider social environments that contribute to mental distress in equally significant ways (Fullagar and O’Brien 2014).

The success of Global Mental Health approaches would likely be accelerated by eschewing the current emphasis on the pragmatics of services in favour of promoting more meaningful engagement with communities (Campbell and Burgess 2012; Kirmayer and Pedersen 2014; Swartz 2012). To achieve this, frameworks that integrate attention to short-term treatment and recovery issues with wider social determinants of mental health are needed.

 
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