Discussion and Conclusion
This chapter describes the emergence of CC, a non-profit organisation for individuals with a psychotic disorder and their families in Matagalpa, Nicaragua, which aims to improve quality of life through education and peer support by the means of home visits and group meetings. In Matagalpa, it is seen that valuable money and energy are wasted when solely focusing on clinical management. If families do not get information on the illness symptoms, management of medication and possible side effects, patients continue to relapse or do not stabilise at all. The experiences of CC suggest the huge potential of family-based interventions to improve the quality of life of people with mental illness and their families in low-income settings. The positive outcome of CC’s approach has so far only been derived from personal stories and surveys. These narrative accounts are important qualitative data, but the organisation faces the challenge to put into practice a structured evaluation programme to monitor its work and prove its success to policy makers.
The Lancet Global Mental Health Group (2007) calls for scaling up mental health services in low-income countries and developing community programmes to improve mental health practice. However, several barriers have to be overcome. In Nicaragua and many similar low-income settings, financial resources are scarce, mental health is a low priority on the public health agenda and there is a lack of knowledge of mental illness among general health workers. The mental health system in Matagalpa is now limited to psychiatrists prescribing medication and/or referring patients to the only psychiatric hospital in Managua. CC hopes that the Nicaraguan government will invest in community-based care. As Murthy expresses it:
Developing countries have an unique opportunity to build mental health programmes on the strengths of families. (Murthy 2003, p. 37)
However, he describes three conditions needed to support a family-based approach. Firstly, families require professional support to develop caring skills and access to crisis support and respite care, as well as emotional support. Secondly, families need financial support to replace income lost through caring responsibilities and to help them establish SHGs. Finally, family-based interventions will require significant shifts in attitudes and practices among policy makers and those working in mental health care to develop partnerships with families and make the experiences of the family an essential part of mental health programme and policy development (Murthy 2003).
As for CC, the organisation has been seeking cooperation with the local government but has encountered financial limitations and little official interest so far. The organisation has also been participating in local health committees and federations over the past ten years, but it is hard to get mental health on the agenda. Although CC could play an important advocacy role in the battle for improving mental health practice, the organisation has very limited skills in this area. The Lancet Global Mental Health Group suggests that the World Bank, other development banks, donor agencies in high-income countries and philanthropists invest in strengthening the capacity of consumer organisations and engage them as equal partners (Global Mental Health Group 2007, pp. 94—95). However, negotiating on a macro level is not an easy task and CC workers do not speak English. The recent establishment of the Central American Network to help empower organisations like CC is grounds for cautious optimism. For the time being however, as with many small NGOs, CC continues to depend on private fundraising activities in the Netherlands and the contribution of Dutch volunteers meaning that the future sustainability of the organisation remains uncertain. The experiences of CC suggest the potential value of family interventions in low-income settings. However, more people could share in these benefits if mental health policy makers prioritise the needs of service users and family members, allocate funds for mental health and reorganise health systems around community-based interventions.
Acknowledgements I want to thank Geertje van der Geest, Gerben Wieldraaijer, Kate Matuszewski, Kees van der Geest, Koen Kusters, Sjaak van der Geest and Wendy Nelissen for their helpful comments on earlier drafts of this chapter. Above all, I am especially grateful to everybody who participated in the research and contributed to CC.