Wide Angle

Community mental health: Theory, practices and perspectives

Operations Division May 2018

WA l 09 2 Author Proofreading & Editing François WYNGAERDEN Aude BAUSSON Sociologist and researcher at the Louvain Stéphanie DEYGAS Catholic University Institute of Health and Society and guest lecturer at the faculty of Traduction public health. Kim BARRETT [email protected] Publication Contributors Humanity & Inclusion Rachel THIBEAULT Operations Division Laetitia FREMONT Sarah RIZK Graphics & Layout Maximilien ZIMMERMANN Frédérick Dubouchet – IC&K Beltza

Photo credits ©Benny Jackson Wide Angle

Community mental health: Theory, practices and perspectives

Operations Division May 2018

Foreword 4 Executive summary 4 Why produce this document and who is it for? 6 Objectives of this document 7

Part 1: community mental health theory 8 1. Community mental health, a brief literature review 8 2. Community mental health and HI 11

Part 2: community mental health practices 14 1. The specificities of HI’s position 14 2. The Projects 20 3. Cross-cutting characteristics 22 4. Types of intervention 23 5. Nourishing our practice: new theoretical input? 28

Part 3: challenges, stakes and perspectives 36 1. Challenges 36 2. Stakes and perspectives 37

Appendices 40 1. Seminar Terms of Reference and Programme 40 2. Bibliography 43 Foreword

Executive summary intervention methods: specialist mental health services (but locally-based and open Mental health problems are commonplace to society), the inclusion of community and affect more than one in four people mental health in primary health care, and worldwide. They are responsible for a inclusion of community mental health in quarter of all disabilities. Humanity & community-based rehabilitation (CBR). Inclusion (HI) has been working in this area since 1990, deploying actions to prevent The second part of this document details mental health disorders, provide care the specificities of HI’s positioning and support for social inclusion, fight the in relation to the mental health and stigma around mental health and disabling psychosocial support sector, based on: situations, and promote positive mental • A wholly social vision of mental health health (see definition page 16). disorders requiring not just attention to be paid to the symptoms of mental A seminar was held in Kigali, Rwanda on health disorders or stress reactions, but 7 - 9 December 2017. It brought together also to the person’s capacity to enjoy life 45 participants from 12 countries (see and meet the challenges they face. the appendiced Terms of Reference and • The importance of social participation, programme) to think about and discuss which aims to give the most vulnerable, community mental health concepts and suffering people a place in society. practices. • A particular focus on the role of the person who is suffering, to ensure 4 Indeed, the mental health and psychosocial they are placed at the centre of the support (MHPSS) sector wants to rethink care process. This involvement leads its intervention methods to best meet the practitioners to abandon the idea that they needs of the populations we support. know what is best for people, and requires the sharing of knowledge and power. The objectives of this document are two- fold: HI runs a variety of projects. These include: • Set out analysis by an external expert, • On the one hand, projects with a mental with a focus on community mental health component integrated into health at HI, in light of the literature and other sectors (the majority of projects), concepts and practices within the sector. such as physical rehabilitation (Iraq, • Undertake preliminary work to identify Afghanistan etc.), gender-based violence new concepts for implementation, based (Rwanda, Burundi) or migration (Turkey, on the aspects covered in the seminar, Bangladesh). as part of ongoing in-depth work in this • On the other hand, stand-alone area, including the updating of the 2011 mental health projects (Rwanda, Togo, mental health framework document. Madagascar, Lebanon, South Sudan etc.).

The first part of this document sets out a The majority of projects have a shared brief review of the scientific literature on identity and cross-cutting characteristics: community mental health, going back to • Community consultation, through a its origins in the 1950s rooted in the de- socio-anthropological study which aims institutionalisation movement, focused on to understand perceptions of mental the importance of decentralising community health issues, the actors in place and the services and involving «secular» or non- power balance between them; specialist actors, in particular in low and • Work with non-specialists, including middle-income countries. At HI, community for the purpose of managing diagnosed mental health mainly refers to three psychiatric pathologies; • Support groups, which for a number of interesting to develop and onboard tools years have been a particular focus for HI. to compensate for this gap. • A transverse psycho-social dimension The interventions take the form of: is likely to be developed in many, if not • Community prevention and awareness- most, of our projects. raising, of mental health issues and • Involving users in their care pathway existing resources; by providing practitioners with tools • Support and development of care (notably those relating to Carl Rogers’ systems, such as referrals to specialist person-centered approach) could be centres, capacity-building of services reinforced. through training and supervision • Mental health projects based on (specialists), the strengthening of community-based rehabilitation, built psycho-social support workers on the expertise developed through (non-specialists), and finally the personalised social support, could also implementation of emergency be developed. psychosocial interventions during crises; • Interventions in emergency settings • Support and development of social could be re-thought as part of the support systems, such as job assistance emergency / development continuum, or income-generating activities; through the prism of our experience in • Support and development of collective community mental health. support systems, such as discussion • Advocacy for robust mental health groups and self-help groups; policies based on the updating of our • Advocacy to influence decision-makers, strategy, could be stepped up. governments and actors to develop fair • An update of our mental health policy and inclusive policies. (framework document) could potentially include the following components: New theoretical input, presented by guest • HI’s vision of mental health and experts, which might give us new ideas psychsocial support projects, which, CMH for HI’s activities: resilience and recovery. based on the components set out in Foreword Resilience can be defined as a dynamic the second part of this document is: A form of learning which allows people resolutely social vision of psychological to bounce back in the face of adversity. disorders and/or distress, requiring the Recovery can be defined as a unique and involvement of beneficiaries in their care personal journey back to a full, meaningful pathway with the clear goal of ensuring life, despite the diagnosis of a psychiatric people’s social participation. illness or mental health disorder. • A reaffirmation of what community mental health is from HI’s perspective, The third section sets out the different bearing in mind that this is largely problems raised in the discussions contained in the 2011 framework between participants: either resulting document. from the contexts in which the projects • Choices in terms of the priority are developed (lack of specialist resources, populations: people suffering from lack of services, stigmatisation), or due to disorders and/or distress typically the ownership of our framework document associated with other physical (disability) on mental health by the people responsible or social (detention, gender-based for the projects. violence etc.) issues, people with moderate to severe mental disorders The main challenges and perspectives for (pre-existing and/or exacerbated by the the future are also discussed in this final context in which HI is operating), people section, and are summarised under the suffering distress relating to the context following recommendations: (war, internal conflicts, natural disasters, • Disability and mental health disorders: vulnerability)etc. there is a lack of information on the • The intervention method, stand-alone mental health problems faced by project or integrated mental-health people with disabilities and it would be component. Foreword

• The tools to use (or not) depending rethink its intervention methods in order to on the contexts and issues identified: best meet the needs of the populations it peer support groups, individual or supports. group psychotherapy, psychoeducation, psychological first aid etc. This document is in no way an exhaustive • A minimum level of competence for representation of mental health and mental health and psychsocial support psychsocial support (MHPSS) at Humanity workers (knowledge, soft and hard & Inclusion (HI). It is based on observations skills). made during the community mental health • Priorities in terms of advocacy. seminar which took place in Rwanda from 7 - 9 December 2017, which brought together 45 participants from 12 countries (Burkina Faso, Mali, Burundi, Rwanda, Cuba, Haïti, Nicaragua, Colombia, Bolivia, Cambodia, Why produce this document Iraq and Nepal). It is also based on a and who is it for? literature review of existing HI documents and scientific articles (see appendiced references), and from informal and formal Mental health problems are commonplace discussions with seminar participants. The and affect more than one in four people mental health technical advisers and the worldwide. This represents 10% of the knowledge capitalisation methodology global burden of disease. These problems technical adviser also contributed to this are responsible for a quarter of disabilities 6 and result from a complex range of thinking. This document is part of a more personal, social and environmental general process to reconsider the focus of situations. These figures are even higher in HI’s future mental health strategy. It will emergency situations. therefore be used to update the current framework document as part of more Humanity & Inclusion has been working in general thinking around the emergency the mental health sector since the 1990s. response-development nexus. It is intended Our actions aim to prevent mental health to develop comprehensive thinking about disorders, provide care and support for mental health and psychsocial support at HI social inclusion, fight the stigma around in emergency response and development mental health and disabling situations, settings. Given the wide variety of contexts and promote positive mental health. All in which HI operates, and the diversity of these actions are implemented using profiles (specialists and non-specialists) multi-disciplinary, participative, community working in this sector, this document aims to approaches which take care to coordinate explore the need for a shared foundation of between the different actors involved. knowledge, hard and soft skills to guarantee the quality of our interventions, regardless of Our interventions have always targeted their diversity. vulnerable and isolated populations such as the victims of war or genocide, This document is intended for HI and orphans, female victims of violence, partner staff members who work in the people with mental, sensory, or intellectual mental health and psychosocial support disabilities, and people living with sector. It is also intended for HI staff disabling diseases. Today, with more working on mental health strategy. It than 30 years’ experience in the field can also be used to feed into the work of working in constantly changing socio- field staff developing, implementing and political contexts, the mental health and assessing mental health and psychsocial psychsocial support sector wants to support programmes. Objectives of this document

These are two-fold: • Set out analysis by an external expert with a focus on community mental health at HI, in light of the literature and concepts and practices within the sector; • Undertake preliminary work to identify new concepts for implementation, based on the aspects covered in the seminar, as part of the ongoing in-depth work in this sector (MHPSS) at HI: updating of the mental health framework document with a view to integrating the emergency response-development nexus and the strategy to implement to multiply and reinforce our prevention and management actions in mental health and psychsocial support.

CMH Foreword Part 1: community mental health theory

1. Community mental health, achieved very positive results in relation to a brief literature review the limitation of psychiatric hospitalisation and in relation to housing stability (Bond and Campbell 2008; Burns et al. 2001; The term «community mental health» refers to a number of different practices. Marshall and Lockwood 2011; Wiley-Exley It refers not only to a movement to 2007). The hospitals themselves have transform mental health care, but also been transformed, offering shorter, more a type of care setting. The use of the intensive care, investing in outpatient care term «community» can indicate the direct and developing day hospitals. involvement of local community actors, but also expresses its difference in relation This community strategy is supported by to care provided through hospitalisation three movements which have had a lasting in a psychiatric unit. In low and middle- influence and are still relevant today: (1) income countries, community mental health attention to the human rights of people projects incorporate a multitude of different with mental health disorders, including the practices, there is no standard model right to live a fulfilling life in the community with a proven track record. It is therefore (2) constant organisational efforts to important that these different meanings integrate the methods used in primary are properly contextualised. health care and community health care into mental health care care (3) scientific research which has proven that community- The origin: based mental health services provide better de-institutionalisation care at a lower cost (Wiley-Exley 2007).

In the western world, the community These community mental health models mental health movement began in the 8 are currently considered to be the best 1950s in response to the institutionalisation way of organising health care for people of psychiatric patients which was found with mental disorders in western countries. to have truly disastrous consequences. They ensure continuity of care and address Patients who spend too long in psychiatric hospitals experience a loss of social skills, people’s needs in a holistic manner, the weakening fo social relationships, and encompassing social and economic issues. difficulties in relation to social inclusion and They also provide early detection and stigmatisation. contribute to reducing stigma. Community care has better outcomes both in terms Numerous community services were of symptoms and quality of life for people developed to address these problems: with severe mental health disorders. They consultation services, rehabilitation are also more cost-effective and uphold services, job assistance and sheltered people’s human rights (Jacob 2001; Jacob et housing (Thara, John and Chatterjee al. 2007; Wiley-Exley 2007; Killaspy 2006; 2014). This became known as the de- Thornicroft and Tansella 2004; Mueser et al. institutionalisation movement. Dedicated 1998). teams were set up to support the most vulnerable people proactively, in their homes, through assertive outreach, without waiting until they were in crisis and needed to be hospitalised. These methods Community mental health They offer consultation, monitoring, psychoeducation, home support services, in low and middle-income rehabiliation and job assistance, group countries activities etc.

There are both extensive discrepancies Although the number of psychiatric hospital and numerous similarities between mental beds is decreasing in favour of these types health care in low and middle-income of services, they are still extremely marginal countries and in western countries. Some in low and middle-income countries. of the challenges faced are very similar: However, unlike in western countries, their mental health systems remain highly where the financial resources allocated to centralised; the majority of mental health mental health are broadly sufficient but professionals work in a limited number need to be reallocated to community-based of psychiatric hospitals located in major care, in low and middle-income countries cities; human rights protection remains merely prioritising community mental health inadequate; and the links with community is not enough, and alternative resources mental health care and front line general need to be found. practice are weak (Chisholm and Thornicroft 2007). They also face the same challenges as western countries in terms of the lack of Alternative resources: time and the focusing of resources (budget and staff) on hospital services to the «secular» actors detriment of community care. Low and middle-income countries face In light of these observations, the first one challenge that is entirely different to recommendation is to create community- western countries: the lack of resources. based mental health services. There are Reforms to decentralise services, although three types of community mental health necessary, are not enough to provide services: decentralised hospital units based patients with the right levels of care and in the community, residential centres in support. It is therefore necessary to deploy the community, and outpatient community other strategies. These strategies come mental health services (WHO 2010). under two main categories: integrating • A psychiatric hospital unit in the mental health care into mainstream services on the one hand, and mobilising non- community is a unit offering residential CMH specialist actors in health, on the other. psychiatric care out of a general care Part 1 unit. This type of unit is usually found in a general hospital or local health centre. These units have the advantage of being Inclusion in mainstream services geographically closer to the populations, and as they are not known as psychiatrict There is an increasingly widespread units, they contribute to reducing stigma. international consens to support the • A residential centre in the community is integration of mental health care into a non-medical residence. These centres general care provision (Petersen 2000; are used by people with relatively Mooren et al. 2003; Henderson et al. 2005; stable disorders which do not require Qureshi et al. 2006; WHO 2001; Chatterjee intensive medical treatment. They are an et al. 2003; Chisholm and Thornicroft intermediate solution between home and 2007; Lund et al. 2012; Kakuma et al. hospitalisation. They are used to manage 2011; Jenkins et al. 2010). This integrated situations before they deteriorate and healthcare offers numerous advantages. It require medical treatment. increases the accessibility of mental health • Outpatient services support people care and provides holistic care, which living with a mental disorder from a takes into account all the patient’s needs, medical and psychological point of and reduces stigma by not differentiating view. They also manage the social between people with mental disorders and consequences of mental health disorders. other patients. This type of model involves Part 1: community mental health theory

raising the awareness of, and involving qualification in mental health or even in health workers in front line services, as well health care. They are usually trained up as providing supervision and delivering over a period of several weeks and work decentralised training sessions for these for a primary healthcare centre or social workers. The aim is to provide these actors services at a location close the population with tools to facilitate the identification in question. Their role is to identify people of disorders: targeted therapeutic who are suffering, to advise and refer them, interventions (including short forms of and to deliver psychoeducation (for patients psychotherapy and managing medication), and their families) and medical and social as well as procedures to facilitate referral to follow-up. They also provide practical and specialist services. material support - this type of support is often crucial, including for assisting people Rather than being included in primary with mental health issues. These activities health care, mental health care can also are implemented either via home visits or be integrated into community-based group sessions. These community workers rehabilitation (CBR) programmes. CBR is often achieve outstanding results, such a form of care widely implemented in the as convincing families to free people with field of physical disability in low-income mental disorders from their chains and start countries (Lagerkvist 1992 ; Evans et to receive psychiatric care (Thara, John, al. 2001). It is a more effective way of and Chatterjee 2014). These community helping people with disabilities and their health workers are also well placed to families overcome the economic, cultural work on empowerment by mobilising and and geographic barriers to inclusion. This supporting vulnerable people to organise type of care and support is based on themselves as a group (Ventevogel 2014; accessibility, active participation, and is de Menil and Underhill 2010; Wright et al. sensitive to social and cultural specificities. 2014). They have received specific training, These types of strategies can also be making them very well placed to assist used to meet the complex needs of people with developing telepsychiatry services with mental health disorders in areas and systems to allow local practitioners to 10 with no psycho-medical resources. They conduct clinical consultations with remote have a proven track record for improving diagnosis and prescription support from symptoms, treatment compliance, and specialists. These services would appear social function (Chatterjee et al. 2003; Dias to be a promising tool for making mental et al. 2008; Rathod et al. 2017; O’toole health care available in isolated areas far 1988; Lundgren-Lindquist and Nordholm from medical centres (Parekh 2015; Rebello 1996). et al. 2014).

Several studies have provided evidence Community health workers that using community health workers is not only feasible, but does actually improve After inclusion in mainstream services, the situation of people with mental health the second most common community disorders. This type of set-up makes it mental health strategy is to make use of easier to look for assistance from primary community health workers (Kakuma et healthcare centres (Chatterjee et al. 2011; al. 2011; Chisholm and Thornicroft 2007; Ventevogel 2014 ; Eaton and Agomoh Saraceno et al. 2007). These are members 2008). The work with families is one of the of the community they work in. They are foundations for this type of intervention. volunteers (sometimes with personal Several studies have shown that working experience of mental health issues) or with families helps reduce the rate of social workers, but do not have an official relapse and improves the quality of life of people living with a severe disorder (Li and to medical/psychological care where this Arthur 2005; Chien, Chan, and Thompson is unavailable. It makes it possible to help 2006; Ran et al. 2003). Family and friends people improve their daily life skills, with can help with detecting disorders, referrals, social relationships and with mobilising finding assistance and day-to-day support. community resources, to help them cope They must be recognised as a vital resource with stressful events such as conflict, in the community mental health system. It is violence and poverty (Kermode et al. 2007; therefore particularly important that family van Mierlo 2012). education programmes are developed and families are helped to build the skills and We also found mentions in the scientific knowledge required to support a family literature of several integrated community member with a mental disorder (Kakuma et strategies, which make use of some of al. 2011). the components of the aforementioned interventions. None of them is conclusive It is interesting to note that the enough to constitute a gold standard. interventions of community health workers The collaborative community-based care are beneficial for patients, even though (CCBC) intervention, for example (Chatterjee they do not use medical language or et al. 2011), is a complete package representations of mental health disorders. incorporating psychoeducation and self- The terms depression or post-traumatic management support, strategies to improve stress disorder are not used and are not treatment compliance, programmes focused needed to be beneficial for patients. This on physical health, rehabilitation and job is important, because more often than assistance strategies, links with self-help not, people with common mental health groups and other peer support initiatives and disorders (depression, anxiety, substance links with other services managing social abuse) do not express their difficulties using issues and access to replacement income. medical terms, but using their own cultural Another example, is the Prime programme representations or in relation to their life (Lund et al. 2012) which also develops experience (Patel 2014, 1995; Aggarwal et service packages which are adapted to al. 2014; Ventevogel 2014 ; Ventevogel et different local contexts by including change al. 2013). management processes to help organise mental health care. One tool commonly used by community health workers is the support group. CMH Community health workers can set up Part 1 and support these groups, with different purposes: peer-discussion and support, information, psychoeducation, income- 2. Community mental health generating activities and any activity to and HI facilitate people’s inclusion in the community. These groups can be powerful tools for Some NGOs - including HI - have drawn on supporting people with mental health the different aspects found in the scientific disorders and their families to become literature to define a community mental genuine care partners and decrease health intervention strategy (HI 2011b, dependency on the healthcare services CBM 2008a, CBM 2008b). (Petersen et al. 2011). The few examples which have been assessed to date have These texts (HI 2011b, CBM 2008a, CBM been shown to have a positive impact on 2008b) describe community mental health the symptoms of mental health disorders as a set of decentralised actions to provide (Richters, Dekker, and Scholte 2008; Scholte accessible, affordable, acceptable, quality et al. 2011; Tripathy et al. 2010). mental health care in the community, for people living with a mental health disorder. Generally speaking, supporting people The main aim of these community mental with mental health disorders using social health services is to improve the quality of work methods is often a good alternative life of people living with a mental health Part 1: community mental health theory

disorder through the early detection of and community support can have. A disorders, access to affordable treatment, comprehensive vision of care management improving social inclusion and securing and active participation is a more recent livelihoods. dynamic in community mental health. It is more than likely that the links HI and other These texts also incorporate some NGOs have with social work methods community mental health values and and community-based rehabilitation are operating principles: partly responsible for the primacy of these • Community mental health involves the approaches. holistic management of the person, identifying all their resources and needs, In terms of operationalisation, the HI including their social, occupational and text of reference (HI 2011b) refers to psychological needs. Consequently, three community mental health service the care management provided is models: specialist mental health services, multidisciplinary, combining legal, social, but provided locally and open to the economic (income-generating activities community; inclusion of community to meet people’s basic needs) and mental health in primary healthcare psychological aspects (discussion groups, services; and inclusion of community individual therapy, income-generating mental health in community-based activities used as mediation). rehabilitation (CBR). These three methods • Community mental health services correspond to the findings in the scientific working with community resources literature. The first corresponds to the type (teachers, community workers, elected of services which should be developed, officials, parents) to put into place support but which generally consume excessive and management mechanisms for amounts of human and financial resources. vulnerable people and/or to refer them to The other two correspond to strategies for the appropriate places for care. inclusion in the mainstream systems, as set • The active participation of people out above. Inclusion in community-based with mental health disorders, as well rehabilitation services, either by adding 12 as their family members, is another a psychosocial component to an existing key value. This involves giving them a project, or by developing stand-alone voice and respecting their right to make mental health disorder projects using this decisions for themselves. It is also about methodology, appears to be an interesting empowering these people and facilitating option for HI, which already has experience their social participation. in this area. • Finally, these texts consider community mental health as an approach which is The HI text of reference (HI 2011b) sensitive to culture and traditions. highlights the benefits of community mental health services in terms of accessibility These principles and values are associated and reducing stigma, which corresponds to with the different conceptions of the findings in the literature. In this sense, community mental health in the scientific they differentiate between formal services, literature, although not systematically. intended for people with severe mental Working with community resources, for illness, involving specialists (for example, example, is closely linked to the process community mental health centres, outreach for developing care in the community, visits to villages, monitoring the inclusive a process which began in the 1960s in employment of users etc.) and informal western countries. These movements services provided by unqualified people developed partly from the realisation of (for example, day-to-day care provided by the positive impact social relationships neighbours). It is important to mention here that the community health workers, extensively described in the literature, fall between these two categories, sometimes veering towards a more formal approach (working with frontline health services) and sometimes towards the informal (volunteers with their own experience of mental health disorders). Furthermore, although these types of workers are very often used when integrating projects into primary healthcare services or CBR services, they are also likely to be used in other contexts. Backed up with tools such as support groups or personalised social support, community health workers could constitute a 4th intervention model, along with specialist services and inclusion in mainstream services (primary healthcare and CBR).

CMH Part 1 Part 2: community mental health practices

1. The specificities of HI’s Positive mental health position Refering back to article 2-8 of the Lyon declaration (The 39 collective, 2011), HI defines good mental health as follows: In light of HI’s practices, three features “The capacity to live with oneself and seem to be characteristic of its positioning others, with enjoyment, happiness, and on mental health interventions: a meaningful life, in a given, but not • a social vision of mental health disorders unmoveable, environment which can be • support for people’s social participation transformed by the activity of people and • placing the person at the centre of the groups of people, without destruction but care system not without upheaval, i.e. the capacity to say “no” to what runs counter to people’s needs and respect for individual and A social vision of mental collective life, which allows the “yes”, health disorders which implies a capacity to suffer whilst remaining alive, connected with themselves HI has a holistic vision of mental and with others”1 (HI 2013). The notion health disorders, including their social, of positive mental health, also used in HI psychological and medical aspects, documents, refers more or less to the same articulating the notion of mental health idea. “It refers to a state of well-being, a and mental health disorders as two feeling of happiness and/or self-fulfillment, distinct but inter-dependent continuums. aspects of people’s personalities (resilience, This has lead HI to consider medical optimism, capacity to cope with difficulties, treatment as an essential component of impression of control over one’s life, self- people’s well-being, but also as one of a esteem). It is a positive state, in balance number of composite parts for the overall and harmony between the individual’s care management, which aims not only structures and those in the environment to to alleviate symptoms to but also, and which people have to adapt.”2 (HI 2011). perhaps most importantly, to improve their When discussing mental health or positive social participation. mental health, the key thing to remember is that we are not only talking about the 14 HI differentiates between health and symptoms of mental health disorders we health issues. This distinction features in can manage or treat. We are also attentive the 1946 preamble to the constitution of to the person’s ability to enjoy life and the World Health Organization. Health meet the challenges facing them (Gilmour is a state of complete physical, mental 2014). From this point of view, mental and social well-being and not merely the health is a question of postiive feelings absence of disease or infirmity. Health is about life and social functioning (Keyes not reduced to the absence of disease, 2002). it also refers to an ability to function and interact with others, to participate in social life. In the same way we can distinguish Mental health disorders between mental health or positive mental health on the one hand, and on Mental health disorders and psychological the other, mental health disorders and distress refer to a range of highly diverse psychological distress. We will discuss conditions and syndromes, with very these concepts in detail herein, and different causes, which cause problems describe how they interact. in people’s lives, psychological suffering, cognitive disorders, behavioural and However, this is a point of debate. For adaptation difficulties. There are numerous some it should form a distinct category in theories on the causes and progression of the nosography, close to «acute reaction mental health disorders, as well as multiple to stress» (ICD-10) or «acute stress» nosographies (the systematic description (WHO 2015). Psychological distress and classification of diseases). The most develops following exposure to severe frequently used of these are the WHO stress factors which threaten a person’s (ICD-10) and the American Association physical and mental health. The person of Psychiatry (DSM-V) classifications. The is no longer able to adapt and develops most common disorders are mood disorders emotional disorders. These disorders (depression, bipolar), psychosis, substance are usually temporary and related to a abuse disorders, and anxiety or stresss- specific event (Horwitz 2007; Ridner related disorders. They present in very 2004). Others consider psychological different ways, both in terms of symptoms distress as one of a number of criteria and the duration of the illness. Some people for diagnosing other disorders (OCD or experience very brief episodes, whereas PTSD) or as an indicator of the severity others find themselves suffering from long- of the symptoms of depression or anxiety term impairments due to their disorders. (Drapeau, Marchand, and Beaulieu-Prévost The latter are usually described as a set of 2012). Furthermore, some use the notion symptoms which often develop conjointly. of psychological distress as an indicator They are associated with psychological, of the mental health of a population in medical and social interventions, which are epidemiological studies or an outcome from usually able to help people. However, it is intervention evaluation studies. In this case, very rare to know exactly why a person has psychological distress is used more as a developed a given disorder and why they general measure of psychological suffering, get better. with no precise distinction between the various disorders likely to cause this suffering. Others even use the notion of Psychological distress psychological distress instead of mental health disorders. They consider that the In development and humanitarian contexts, term «mental health disorder» expresses a we typically make a distinction between medical understanding of a phenomenon, psychological distress and mental health and thus prefer to use «psychological disorders. Psychological distress is a distress» which they believe refers to a concept which is not very precisely defined psycho-social paradigm. These authors are (Ridner 2004; Drapeau, Marchand, and usually focused on the social construction Beaulieu-Prévost 2012). It is usually of disorders and how people live with them defined as a state of emotional suffering and interact with others (Coppock and CMH characterised by symptoms of depression Dunn 2009). Part 2 (loss of interest, sadness, dispair) and anxiety (agitation, tension). HI defines HI prefers to use the first interpretation it as «a sate of disquiet which is not of psychological distress, i.e. a relatively necessarily symptomatic of a pathology indistinct set of symptoms of depression and or mental disorder. It signals the presence anxiety which develop in contexts of acute of, non-severe or temporary, symptoms stress. Regardless of the definition used, of anxiety and depression which do not care must be taken to not create a false meet the criteria for diagnosing mental dichotomy between psychological distress disorders and which may be a reaction to and mental health disorders. There is often stressful situations (migration, exile, natural a very fine line between undefined disorders disaster which can induce symptoms of which develop in reaction to a situation and psychological trauma) or to existential diagnosed mental health disorders. There difficulties.» (HI 2011). is not necessarily a substantial difference between the two but they form different Psychological distress is not actually part of stages along a continuum of severity. Losing the nosography of mental health disorders. sight of this can impede both management Part 2: community mental health practices

and treatment. For example, some authors and to specify that these two dimensions concluded that psychological distress should are correlated, but not synonymous. This first be managed with empathy, social is the interpretation proposed in the two- support and understanding, as opposed continuum model (Keyes 2002; Keyes to mental health disorders which require a and Simoes 2012; Keyes 2007; Keyes, medical intervention. In the ensuing debate, Dhingra, and Simoes 2010) which HI uses other authors raised the point that all mental in a number of its documents (HI 2011b, health disorders need to be managed with 2013). From this perspective, mental health empathy, social support and understanding and mental health disorders constitute (not just psychological distress) and that two distinct, but correlated, axes, one all mental health disorders are in part due representing mental health (presence or to reactions to stressful social situations absence) and the other mental health (Goldberg 2000). disorders (presence or absence). The two continuums are distinct because a person can be in good mental health even with a Two continuums mental health disorder. However, studies have shown a correlation between the Suffering from a mental health disorder does two. Good mental health protects against not necessarily mean having poor mental mortality, regardless of cause. Suicidal health, and poor mental health does not behaviours and an improvement in mental necessarily mean having a mental health health were also associated with a lower disorder. The key is to distinguish between risk of a mental health disease (Keyes and mental health and mental health disorders Simoes 2012; Grant et al. 2012; Keyes, Dhingra, and Simoes 2010; Keyes 2007).

THE TWO CONTINUUMS OF MENTAL HEALTH

For example: a person with For example: a person who is able schizophrenia who, over the course Good mental health to bounce back when faced with of a personal recovery process difficulties in their life and if they do

16 has established new life goals and experience symptoms these are not

socially-valued roles so overwhelming that they constitute a psychiatric pathology.  Severe mental   No mental illness

For example: a person with post- For example: a person who has not traumatic stress disorder who received a psychiatric diagnosis but is struggles to manage their illness and struggling to find meaning in their life cannot commit in the long-term to a Poor mental health and accomplish everyday tasks. job or other social activity. The benefit of considering mental health The disability creation process and mental health disorders on two continuums is that it allows for a more The disability creation process (DCP), social approach to their management. The cited in several HI documents (HI 2011b), aim is not only to reduce the symptoms attempts to find the middle ground between: of a disease, but to support the person • social models which consider disability to help them find their place in the as a disadvantage resulting from social community. Furthermore, this support exclusion, and which solely focus on work is relevant whether the person is structural environmental barriers to social suffering from a severe mental health participation, and disorder or not. • bio-medical models, focused on supporting people and developing skills to cope with the disadvantages associated with their Disability and social impairment. participation The DCP aims to document and explain the causes and consequences of illness, trauma We have already broadened our and other damage to a person’s integrity or understanding of the situation of development. The model applies to everyone people with mental health disorders by regardless of the cause, nature or severity of considering two continuums, one with their impairment. It considers that the quality a medical vision of disorders, focused of each person’s social participation is the on alleviating symptoms (mental health result of interaction between characteristics disorders) and the other in relation relating to organic, functional and identity to a positive vision of life and correct aspects, and the characteristics of their life social functioning, which introduces a context. psychosocial dimension. The notion of disability allows us to drill down into In order to assess the quality of social the social dimension of mental health participation, the DCP model focuses on disorders. It focuses our attention on describing «life habits» which are defined as social participation and the transformation daily activities or social roles valued by the of society required to ensure this social person themselves and their socio-cultural participation. context, depending on their characteristics (age, gender, socio-cultural identity, etc.). First of all, a distinction must be drawn These include everyday activities (going between impairment and disability: an to bed or getting up, eating etc.) and other impairment refers to a mental or physical activities which take place at varying disorder experienced by a person, whereas frequencies (shopping, budget planning, CMH a disability has a social dimension raising children etc.) (Fougeyrollas et al. Part 2 incoporating the person’s interaction 1998; Noreau and Fougeyrollas 1999). The with their environment. The social model DCP considers full social participation to be of disability developed from the 1970s reached when all life habits can be done. In onwards, asserts that the individual with this way, measuring the accomplishment an impairment is not disadvantaged in of life habits is a way of producing a relation to other people3 because of their quality indicator for social participation: it impairment, but because the physical and is asessed on a continuum or scale ranging social barriers society puts in their way. from optimal social participation to a fully From this perspective, an impairment is a disabling situation. reality that is specific to a person, whereas a disability is social and collective reality. The DCP shows that accomplishing life It is the social reaction to a social disorder habits can be influenced by capacity-building which is in play, and which can cause an or compensating for disabilities through impairment. An impairment is a medical rehabilitation and technical aids, as well as issue, disability a political one (Winance by removing barriers in the environment. 2008). These barriers include prejudice, a lack of Part 2: community mental health practices

Risk factors Cause  Personal factors Environmental factors

Organic systems Aptitudes

Integrity  impairment Capacity  incapacity Facilitator  Obstacle

  Interaction    

Life habits

Social participation  Disabling situation

aid or resources, poor accessibility at home characteristic of a person with a disease, or school, difficulties procuring adapted but as the interaction between the person printed information or a lack of accessible (impairments, disabilities, identity) and their signage hindering people’s movements. The environment (barriers) leading to social DCP proposes practical tools to assess and exclusion (disabling situations) in certain 18 support people’s social participation, but areas of their lives (HI, 2011). also reminds us that we cannot infer the possibilities for social participation from a diagnosis or functional profile. Nor can we Community-Based Rehabilitation disregard the context, activities and social roles which are important to the person Another key component of HI’s projects themselves (HI 2011). to further people’s social participation is community-based rehabilitation (CBR). The term disability is not commonly used This is a community development strategy in the mental health field where it is targeting rehabilitation, equal opportunities generally associated with an intellectual and social participation for all people with disability (i.e. what used to be known as disabilities. Implementing CBR requires mental retardation). However, the social a conjoint effort from the people with exclusion experienced by these people with disabilities themselves, their families, and mental impairments certainly contributes their communities, as well as the social, to the social and cultural construction of health, education and training services (ILO, disability, which is no longer defined as a Unesco, and WHO 1994; WHO 2011). The objectives of CBR are to: Its ability to mobilise the concepts of • Ensure people with disabilities and disability and social participation, as vulnerable people can maximise their well as tools such as community-based physical and mental capabilities, access rehabilitation, is what sets HI apart in its the services and opportunities available implementation of mental health projects. to the general population, and actively The aim is to support vulnerable people contribute to the life of their community to give them a place in society, provide and society as a whole. them with the tools they need to play this • Mobilise communities to promote and role, and transform society to give them protect the human rights of people with this place. It should also be highlighted disabilities through consistent reforms, that CBR guidelines apply to all people for example to remove barriers to social with disabilities, including people with participation. mental health issues (Khasnabis et al. 2010; Chatterjee et al. 2003). Many As a component of social policy, CBR of the problems affecting people with promotes the rights of people with mental health issues are similar to those disabilities to live within their community, which affect other groups of people enjoy good health and well-being, and fully with disabilities. It should be noted that participate in educational, social, cultural, supporting giving this place to people with religious, economic and political activities. mental health disorders does not mean neglecting the medical aspects. Access In practice, CBR involves working with all to appropriate care, including medication, relevant actors to ensure the full participation remains a necessity, but the objective is of people with disabilities in the social lives much broader: social participation. of their families and communities. CBR programmes can provide aid and assistance to people with disabilities to allow them to access social opportunities and fight against User involvement stigma and discrimination, in order to effect positive social change. Social work can take Involving users in their care and support is different forms within a CBR approach. a third vital feature of HI’s projects. This is Firstly, in a context where there are resources the logical follow-on from the points made available, but these are not accessible, it is above. The first step towards giving people possible to put into place services people with mental health disorders a place in the can come to and obtain the information community, is to ensure they are involved their require. When populations are isolated in their care. The active participation of the and experience difficulties identifying their people supported is required at all stages: needs, a personalised social support system from diagnosis via the drafting and setting CMH can be introduced. Finally, in cases where up of a personalised project, through to there are no services, or these are very exiting the system. Their participation is also Part 2 underdeveloped, the social facilitator may beneficial in terms of the organisation of care sometimes be trained in basic rehabilitation, more generally (HI 2009). employment inclusion, education and other skills in order to provide a minimum It is important to distinguish between response to facilitate the implementation of beneficiary involvement and social personalised projects (WHO 2011; HI 2009). participation, as discussed in the previous In this type of community practice, the role point, which aims at the inclusion of people of the social facilitator is to create links and in their community, developing activities mediate between the populations and the which are meaningful for them, and which different actors which make up the person’s allow them to connect with others. The network of relationships (family, friends, disability creation process and community- employers, representatives of institutions, based rehabilitation focus on developing the non-profit partners, other professionals, etc.), person’s capacity for action and their social and the services made available (WHO 2011; participation. However, they also involve HI 2009). supporting beneficiaries to allow them to Part 2: community mental health practices

make their own choices and develop their This support position is mentioned own projects, and this is what we will now throughout HI’s documents. It is said to turn our attention to. require listening skills, empathy and an ability to value people. The practitioners This brings us close to the concept of who adopt this approach develop a empowerment which aims at making specific capacity to explore people’s wants, people autonomous actors in their objectives, resources and strengths. It is own lives. It is a process for taking about having a positive attitude focused back control of their own situations. In on «what we can do» rather then «what we practice, interventions in this area should can’t/can no longer do». (HI 2009). However, allow people to analyse the constraints it is important to note that this specific inherent to their own situation and to free attitude is mostly detailed in the documents themselves of these (Center for Global describing social work such as community- Health, Trinity College Dublin, Ireland, based rehabilitation or personalised social Ahfad University for Women, Sudan, and support. It is not yet at the forefront of HI, France 2014; HI 2013). mental health projects.

This also comes close to the concepts of Whilst it is important to support people’s resilience and recovery developed below. involvement in their care as an individual, These two concepts help us to understand this also needs to happen collectively. that each person goes through a rebuilding Involving beneficiaries in the definition of the process which is individual. Each person project objectives, for example, can be a way can call on a range of resources throughout of ensuring success. It helps to improve the this process, but ultimately it is the person relevance, impact, flexibility, adaptation to themselves who will do the work needed the local environment, and sustainability of to get better, and no-one else. This justifies projects. Participation gives the population giving people a say in their own care the opportunity to keep or take back control pathway. of the decisions that concern them, and to feel like a stakeholder in the interventions. Involving people in their own care pathway requires the professionals and caregivers Supporting vulnerable populations to involved to position themselves in a very take part in the planning, development, specific way. They need to be capable implementation and evaluation of 20 of addressing the most vulnerable, and health policies is also beneficial. HI of developing appropriate methods thereby supports the development of throughout the process to reinforce networks of people with disabilities, their the impact these people have on the families, communities and mental health organisation of their own care(HI 2009). professionals, in order to develop joint They also need to abandon the idea advocacy for the inclusion of these people in that they know better than the person developing the public policies which affect themselves what is best for them. They them (health, social, education, justice). need to support people in their choices, using their strengths as leverage. Obtaining user acceptance of the intervention is not easy for professionals: it requires acknowledging the value of knowledge, 2. The Projects experience and shared decision-making. It can lead to a certain amount of confusion Out of the 12 countries which participated around roles and uncertainty in how in the community mental health seminar organisations operate (HI 2017). in Rwanda from December 7 - 9, 2017, six presented projects: Rwanda, Haiti, peacebuilding missions (Syria, Gaza, Bolivia, Cuba, Colombia and Burkina Faso. Uganda, South Sudan, Somaliland, Although the projects are all different, we Bangladesh, etc.). can differentiate between: • Migration & MHPSS (Turkey, Bangladesh, • Projects where a mental health Middle-East, Ethiopia, Mali, etc.). component is integrated into other sectors (the majority). Stand-alone mental health projects are • Stand-alone mental health projects specifically focused on mental health (Rwanda, Togo, Madagascar, Lebanon, issues. In many projects, these mental South Sudan: Touching Minds Raising health issues are naturally associated with Dignity). traumatic events or particularly stressful contexts, but the primary objective is to The main sectors into which mental health manage people’s psychological suffering. is integrated are as follows: Events such as the genocide of the • Physical rehabilitation: these projects Tutsis in Rwanda, along with a deep- mainly target people who have a physical rooted feeling of insecurity resulting problem. This may be related to an from repeat cycles of violence, have amputation, a road accident, a mine fragilised entire populations. In refugee accident, or a chronic disease such as camps, many people find it difficult to diabetes. HI also develops projects for adapt to the upheaval they experience specific sub-groups such as children with and the harsh living conditions. Prison disabilities. The projects for these types also generates or exacerbates a range of of populations are first and foremost mental health issues. However, to the best focused on physical rehabilitation of our knowledge there are no specific interventions and care. Psycho-social mental health projects focusing on severe management is therefore a welcome mental illness such as psychosis or mood addition to the mix, as people often find disorders. it difficult to cope with the consequences of their disability (Afghanistan, Turkey, Most of HI’s projects belong to the first Jordan, Iraq, Libya, Syria, Yemen, category (integrated into other sectors). Lebannon, Kasai (DRC), Somaliland). They first and foremost address physical • Gender-based violence, child protection, and social problems and subsequently the Assisted Voluntary Return & Mental psychological consequences of these as Health and Psychosocial Support a complement. Of course, this does not (MHPSS): Promoting safe schools in mean we can anticipate the type of mental conflict zones (Burundi); MHPSS for health disorders or their severity. The victims of sexual violence (Ubuntu Care - psychological symptoms these different Rwanda, Burundi, Kenya, Juba: a mobile projects encounter are potentially the same: CMH team in South Sudan). distress, depression, anxiety, fear, apathy Part 2 • Support for civil society & mental health etc. Furthermore the resulting stigma and and psychosocial support: Supporting discrimination are a cross-cutting issue civil society organisations to uphold which adds an additional layer of difficulty the rights of people with mental health regardless of the original problem. issues, making recommendations for inclusion and service provision (China, It is important to distinguish between components of the Touching Minds, these different methods in order to identify Raising Dignity programme). the specificities of the community mental • Sexual and Reproductive Health, Mother health projects developed by HI. Are they and Child Health, AIDS & MHPSS a complementary component of other Projects (WISH Project, Senegal, Mali). projects or are they stand-alone projects? • Inclusive Education & MHPSS (Growing together, Bangladesh, Thailand and Regardless of the project method Pakistan) (integrated or stand-alone) they have • Emergency psychosocial interventions certain shared characteristics which are in conflict zones, natural disasters, set out below. Part 2: community mental health practices

3. Cross-cutting characteristics and local authorities. They support people, through dialogue, to assess what needs The following characteristics are probably to be done, what is feasible or not, the not systematically found in all projects, but objectives that need to be supported. do appear to form part of the identity of HI They carry out home visits, provide family/ projects. psychological support as part of acceptance, and put into place technical actions (medical equipment). They often play a central Community consultation role, which ensures their interventions are coherent and coordinated, and avoids implementing contradictory actions, etc. Community consultation, notably via a socio- anthropological study, allows HI to identify the actors in place, the influences, the power balance between actors etc. This is the basis of all HI projects. Community consultation RWANDA requires an analysis of the mental health In the wake of the genocide of the Tutsis issues experienced in communities and an in Rwanda, HI identified large numbers understanding of individuals’ cultural context of people affected by, or likely to be and constraints. affected by, mental health issues. Certain target populations are particularly In many situations, it is vital that we work vulnerable: child heads of household, with religious and community leaders, female victims of violence, children and notably by setting up project consultation teenagers with or affected by HIV/AIDS, committees responsible for promoting the child mothers, prostitutes, young people project within the community, issuing advice, in poverty, widows (due to the genocide and resolving conflicts. These committees, or HIV/AIDS). composed of influential members of the community, are tasked with helping to The project developed in this situation define the most locally relevant intervention was based on community participation, strategy and to inform the community about aiming to restore social connections, the project and its activities. communication and get solidarity mechanisms within the community 22 working again to support and manage Work with non-specialists vulnerable people and improve their mental health. The key component of We feel it is important to support the work this project was to identify and train of non-specialists, who may be required to focal persons within communities who intervene in any type of situation, for any can activate this community leverage type of problem, including for diagnosed (HI 2009a, 2012c, 2012d). These people psychiatric pathologies. Non-specialists may mediate between the beneficiaries also be community health workers who we have already talked about extensively in the and other bodies, making referrals previous section. However, they can also be as appropriate given the problems social workers who play an important role experienced by the beneficiaries. Each in many projects. They are responsible for focal person is responsible for several secondary prevention, i.e. early screening, «groupings» and takes on the role of advice, basic psychological support, case an elder or «parent» for orphans. This management coordination, and for working «parental» role restructures individuals in networks with other actors, municipalities and sets boundaries for them. Support groups the most vulnerable populations, as well as marginalised people. HI has paid particular attention to support groups over the last few years and they One intervention method would appear have become a central part of our mental to be particularly appropriate in this type health intervention. of situation: the Information, Education, HI has produced numerous documents on Communication programme (IEC). IEC is the relevance, organisation, and facilitation an intervention which aims to provoke of these types of groups: or consolidate changes in behaviour in • A guide for facilitators of prison support target individuals, in order to promote groups(HI 2012b). A practical guide to their well-being. This is a learning process facilitating discussion / emotional and though which individuals and communities sex life groups (HI 2007). voluntarily adopt and maintain behaviours • A training module on facilitating which are beneficial to their health. free expression discussion groups (Madagascar programme). • The discussion group for mothers Support and development of of dependent children with physical the health care system disabilities in Algeria, capitalisation document (HI 2009b). Some of HI’s projects related to mental • Research into the emergence and health aim to set up and develop structuring of support groups for people community mental health care services. in prison with mental health issues in This may involve directly organising Togo, Madagascar, Lebanon and South services, in collaboration with local Sudan (HI 2016, 2017). partners, or developing local service capacity and operators.

Mental health care and referrals 4. Types of intervention HI puts into place mechanisms for referring There are a wide variety of mental health vulnerable people to different services and psychosocial support (MHPSS) (health, education, basic needs, specialist interventions. At HI these can take the mental health services etc.). This requires form of: liaison and coordination mechanisms with • Community prevention and awareness- specialist partners to facilitate access to raising care. • Support and development of the health CMH care system In some projects, referrals are managed Part 2 • Support and development of social by creating referral groups which bring support together professionals from different • Collective support mechanisms organisations and horizons. They use a • Advocacy screening tool and review the situations of patients with mental health and physical disorders. The aim, in conjunction with a HI Community prevention and psychologist, is to assess the need to refer awareness-raising them to a specialist, and to support the professional in the process of assisting the HI develops projects to mobilise and person and their family. raise the awareness of communities. These projects aim to change people’s HI also supports multi-disciplinary mental representations of mental health, or to health teams which provide individual promote behaviours which favour good psychotherapy consultations, guidance, mental health. These actions may target home visits etc. Part 2: community mental health practices

Capacity-building for services authorities, legal advisors and lawyers, health and social centre staff, teachers, HI works to reinforce specialized mental vocational training trainers, managers of health services, notably to support their organisations. HI is able to mobilise the structuring and improving the functioning following tools: of their collective organisation: democratic • Training and awareness-raising of non- practices, management, administrative and specialist mental health care personnel (HI financial management, etc. In some projects, 2011). HI helps to develop and implement an • Training and support for institutional institutional plan i.e. a set of coherent actions managers: in order to implement defined through shared objectives and sustainable projects managers also need focused on people’s needs. The intention is to be trained to be able to support workers to build a vision, a strategy and set short, in the field. If this does not happen, the medium, and long-term objectives. This latter will find themselves in difficulty, then makes it possible to determine how the recommending interventions they cannot teams will work, the internal organisation, put into practice. the role and place of each person, the • Clinical supervision: the aim of supervision decision-making and regulatory bodies, is to provide support for each team relationships with the exterior, and all member individually to work on their aspects of the proper functioning of services. relationship to the situations of vulnerable From a practical point of view, one of the people in order to consolidate their objectives of a HI project should be to ensure professional autonomy. that adjustments are made to the premises • Analysis of professional practice: the aim to ensure they meet the sanitary needs for of this analysis is to allow professionals to the service(HI 2011). reflect on their practices with their peers and to find practical resources relating HI also organises seminars and workshops to the difficulties they may encounter. to support the setting up of national This activity also aims to prevent burn- collectives/forums of mental health out(HI 2012a). In the same vein, there professionals/institutions. HI supports the are discussion groups, such as Balint, for development of local associations and professionals. Faced with illness, suffering services working in networks, allowing them and death, health professionals need to share their experience and communicate space to share and maintain a so-called 24 on the impact of the approaches instigated, professional distance from the people in order to ensure the continuity of care for helped (HI 2009c). These groups should people in psychological distress and/or with ensure workers to not find themselves a mental health disorder. isolated, build their confidence in their own practice, and give them the opportunity to share their knowledge and experience, etc. Capacity-building of psychosocial support workers

HI has developed numerous tools and practices to provide technical support LEBANON to health professionals concerning This project was deployed in the enabling relationships, quality of care, Palestinian refugee camps in Lebanon. pyschopathology, etc. These can be used Originally, a study backed by HI into the by all sorts of community workers: primary situation of children in this type of camp school teachers, elected officials, technical revealed the precarity of their living workers, the health, social and education conditions which lead to many children developing mental health problems Psychological first aid (Maamari and Pégon 2012; HI 2010). These children face significant difficulties: The aim of this type of intervention is to their parents’ unemployment, violence provide immediate relief to people exposed within the family, neglect, poverty, an to potentially traumatic event(s). It involves uncertain future, political instability and providing practical care and support, insecurity, chronic conflicts and precarious which does not intrude; assessing needs living conditions. They can develop a and concerns; helping people to address number of symptoms: enuresia, anxiety, basic needs (for example, food and water, mood disorders, behavioural problems, information); listening to people, but not difficulties constructing satisfactory pressuring them to talk; comforting people relationships with their entourage, and helping them to feel calm; helping isolation and cognitive difficulties. people connect to information, services As part of this project, HI supports two and social supports; protecting people types of centres: from further harm (WHO 2012). This is • Resource and referral centres, located a very specific type of intervention. It is in the camps and run by two social used in projects deployed in emergency workers. These centres facilitate access settings. to specialist services and non-specialist services and build links between actors in the education and health sectors. These centres provide guidance and Support and development of information for families, set up training social support for community workers and run awareness-raising campaigns. HI also develops support projects and • Mental health services centres or projects in collaboration with social and health care centres in the community community services or focused on social These services are staffed by multi- inclusion. These projects mainly call on disciplinary teams including specialised social workers or community workers therapists and community workers. (volunteers or employees). Their role Care is provided at the centre, at home, involves acting as the intermediary between or at school. The team also supports the beneficiaries and the specialist services parents and helps them to get involved by means of appropriate referrals. They also in their child’s care plan, through play a part in mobilising the community, interviews, advice, training, and group so that beneficiaries and communities awareness-raising. as a whole increase their capacity for self-management. These workers are CMH trained and benefit from intervisions The health care centres and referral and Part 2 (practice sharing between peers), liaison resource centres are complementary. mechanisms with other services and a large They work in coordination, notably on panel of tools that can be used according to referral and awareness-raising activities. the needs: The project calls on both professionals • Individual and family interviews: the aim is and non-specialist community workers. to provide individual support and assess Various mechanisms within the project the state of the most vulnerable in order allow them to share their different types to provide psychological support. These of expertise. For example, scaffolding interviews identify the most vulnerable meetings are held each week to build on people requiring support and can help good practice. with any referrals required. • Family mediation: the aim here is The main objective for HI’s technical team to construct or reconstruct a family is to coordinate and share approaches, relationship damaged by a rupture or and to pass on its expertise and know- separation. This work is often combined how on disability and mental health. with group work. Part 2: community mental health practices

• Information, Education, Communication The specificity of PSS is that it is not solely programmes (IEC) which can be focused on the person, but also includes specifically used in this framework as a matching with the services available, tool for the psychoeducation of people finding solutions and adapting these to with mental health disorders. each user’s situation, and preparing them to • Drafting of a support plan: the aim is to receive the support provided (HI 2009d). determine how the needs can be met Personalised social support (PSS) is not as part of any of the activities deployed. yet used in its own right in HI’s community In other contexts, this plan is called the mental health projects. However, it «personalised life plan». This project is does group together numerous tools established with the person themselves to already used in these projects and meet their general and specific needs, as which correspond to values upheld by part of an approach to promote their long- HI, including social participation and term inclusion. It incorporates personal beneficiary involvement. (diseases, impairments, aptitudes), and environmental factors, as well as life habits. • Income-Generating Activities (IGA): these Collective support mechanisms are livelihood activities which require little (support groups) financial, human or material resources. The aim is not only to increase people’s Social support mechanisms also use resources, but also to improve their well- collective i.e. group support tools. These are being and quality of life by enabling them very frequently used in HI’s projects and are to activate themselves the economic and considered to be an extremely important community resources needed to meet part of the whole range of tools HI can use their basic needs (HI 2016). in its mental health projects. • Job assistance: this involves support the person to identify personal goals and Several studies have been carried out within undertake training or help them in their HI in recent years to investigate these relations with potential employers. groups and their use in the organisation’s projects (HI 2016, 2012a, 2012b, 2017). Personalised social support (PSS) is a Here we will mainly focus on two types of framework which incorporates all of these groups: discussion groups and community 26 different tools and which clarifies the role self-help groups. Both types of group target of social workers. It aligns actors with a beneficiaries and their family and friends. series of fundamental values. The aim We will not detail here group practices of PSS is to improve vulnerable people’s targeting health professionals (see above). social participation and living conditions through outreach programmes providing social support adapted to each individual’s Discussion groups needs and resources. It builds their self- confidence and their faith in their abilities. L’objectif de ces groupes est d’améliorer la On a practical level, this support helps to: santé mentale des personnes vulnérables • Mobilise individuals, families, par leur participation à un groupe de pairs organisations and communities favorisant la dynamique de groupe, les • Reduce inequalities and injustice through interactions et les liens entre les participants. the inclusion of marginalised, vulnerable, Le groupe de parole favorise la verbalisation excluded and at-risk groups du mal-être, encourage les échanges et • Effect social change (application of laws, la création de liens sociaux. Ces groupes influencing social policy). peuvent avoir une vocation The aim of these groups is to improve the mental health of MADAGASCAR vulnerable people through their participation Prison overcrowding, in rundown in a peer group that encourages a group buildings with no or very substandard dynamic, interaction and connections sanitation and hygiene facilities, has between participants. Discussion groups very severe consequences on the health encourage participants to verbalise their of inmates. The duration of detention discomfort, to share with one another, and to create social connections. These groups often causes family breakdown may have a purely therapeutic purposes and exacerbates the isolation and and be facilitated and organised by health psychological discomfort resulting professionals. They also offer a form of peer from the incarceration. Access to care support when managed by the participants is difficult, the quality of care is limited themselves or social workers who may have and the prison authorities struggle to experienced the same kinds of difficulties. tackle these issues. HI has identified numerous problems: relating to the hygiene conditions and nutrition, to the Self-help groups social recognition of detainees, to the lack of professional inclusion processes, The aim of these groups is to improve the to the access and the upholding of rights, mental health of members of the Community as well as to political and institutional Self-help Groups (CSG) by helping them problems. make the most of their economic, social In order to tackle these issues, HI has and community resources themselves developed a project consisting of three (collectively), thus enabling them to meet interdependent and complementary their own needs/wants. components (health and nutrition, legal and psychosocial): Advocacy • The psychosocial component includes educational and socio-cultural activities; discussion groups during In this way, HI supports the deinstitutionalisation of mental health by the person’s incarceration and prior developing networks of health, social and to their release; support activities to community professsionals and supporting maintain links between prisoners and coordination between them. HI in this way their families; individual psychosocial attempts to influence the relevant authorities interviews; professional inclusion on this subject and may even take part in activities; and activities to support their drafting or revising national mental health return home. policies or providing its technical or financial • The legal component includes CMH support to implement or reinforce a national upholding the rights of prisoners and Part 2 mental health plan. former prisoners and helping draft requests for early release. • The health and nutrition component includes care and monitoring of prisoners suffering from malnutrition, access to care, management of the nursing staff, promotion of hygiene practices. Part 2: community mental health practices

5. Nourishing our practice: 2. The second reaction is «resilience» which corresponds to the healthy mobilisation new theoretical input? of the individual’s internal and external resources which translates into the Two guest experts were invited to share restoration of the state of well-being their expertise with us at the seminar: Prof. preceding the trauma or crisis. Rachel Thibeault (University of Ottawa) on resilience and Mr. François Wyngaerden 3. The third reaction is known as «post- (Université Catholique de Louvain) on traumatic growth» and corresponds to recovery. the mobilisation of internal and external resources which ultimates leads to the individual attaining a state of improved well-being in comparison to their initial Resilience situation prior to the trauma. The trial leads the person to develop a latent What is resilience? potential by forcing them to meet challenges which require resilience and Long defined as an innate capacity to are meaningful to them. cope with the trials of life, resilience is now understood as a dynamic learning Individuals who show post-traumatic process which not only helps people cope growth are the focus of research into with crises, but allows them to bounce resilience because they are the best placed back from the psychological disruption to identify the keys to this move towards inevitably experienced as a result. It is improved well-being. Their strategies most now considered utopic to imagine that often combine cognitive components, a person can go through a crisis with emotional anchors, and tangible gestures no psychological impact and this new which allow them to cope with their testing definition takes this into account by circumstances in the most versatile, efficient, presenting resilience as a skill that can be and sustainable way possible. learned and maintained and allows people to regulate their response in the face of Drawing on neurosciences, conventional adversity. Feeling distressed or sad is not a psychology and recent research into sign of a lack of resilience, but the sign of intentional activities, therapists specialised in 28 the first stage of the resilience construction resilience have based their approach on four process, which will allow the person to main aspects: outlook, intentional activities, return to their initial state of psychological resilience-building attitudes, and emotional well-being, prior to the situation of regulation. adversity.

In a crisis situation there are three standard Outlook reactions: 1. The first reaction is known as «inadequate Martin Seligman, the award-winning resolution» which corresponds to an researcher at the US National Institute individual’s inability to mobilise the of Mental Health has produced the most internal and external resources required influential work on the impact of outlook to return to their initial state of well-being. on resilience. He has clearly demonstrated The person remains in a depressive or that resilience, and even happiness, anxious state which becomes chronic and depend on a fundamental choice every underpins their entire existence. young adult has to make one day or another, regarding their ideal life. There are distinct forms: the first involves tidying four possible scenarios. up or putting things away (for example: doing the washing up, dusting etc.), A pleasant life in which the ideal is a quest and the second vigorous exercise (for for comfort. The person wants to avoid any example: skiing, jogging etc.). Both types effort or pain, this is a utopic choice which of activity generate dopamine and remove rapidly undermines resilience. Resilience is the restlessness which can often act as a forged by meeting and overcoming regular, barrier to deep centration. By evacuating calibrated psychological challenges, the the disruptive tension, these activities inertia of this scenario results in atrophied form a kind of necessary preamble to a resilience. state of mindfulness.

A good life in which the ideal is to develop 2. Contemplation: These activities cover one’s talents but in a narcissistic manner. It all conventional and non-conventional is possible to choose to do a certain sport, mindfulness strategies. Contemplation for example, purely for the selfish pleasure can include prayer, meditation, calm one derives from the activity. This choice observation of nature, silent relaxation in does however, present certain challenges the bath or any other practice which leads and allows the person to develop the to a sustained state of mindfulness. rudiments of resilience. 3. Creation: These activities are based on A meaningful life which like the good life doing, on the act of creating something. focuses on self-fulfilment but in this case This is not only about creation in an for the greater good. The person develops artistic sense, but about producing a their talents with an altruistic aim, as part work or a new and pleasant experience. of life plans which aim to give back. This Successfully following a recipe, a well- choice usually results in much higher levels written letter, an attractive picture, a piece of resilience than the first two scenarios. of knitting: all these forms contribute to building resilience. Not only does the A full life which includes all the act of creating build resilience, but the components of a meaningful life but also act of genuinely appreciating something includes a further component: an ability someone else has created (music, food, to take pleasure in the little things in art etc.) also reinforces resilience, although life. Whether that might be a sunset, a to a lesser extent. child’s laughter or good food, a day-to- day attitude of wonder and gratitude 4. Contribution: these activities refer to contributes significantly to building opportunities for people to give back. resilience. People who adopt this ideal Whether this may be through voluntary CMH combining altruism and gratitude appear work, a job well done or mutual support, Part 2 to cope better with life’s trials and altruism is one of the pillars of resilience. tribulations. Research has confirmed the massively positive impact of this strategy, even for highly vulnerable populations. Intentional activities 5. Connectedness: Connectedness refers The work of numerous researchers, to activities which develop a sense of including Lyubomirsky and Fredrickson, belonging and connect us with the living has established that resilience largely world in all its forms. This might be a depends on regularly engaging in activities family dinner, a football game with friends, which generate dopamine, serotonin, and a morning spent gardening or playing with other neuro-transmitters associated with a pet. All these situations contribute to psychological well-being. These activities, developing and improving the significant known as eudaimonic intentional activities relationships (with people, animals, plant can be divided into five categories: life) which weave the fabric of our lives 1. Centration: These activities take two and represent key anchors of resilience. Part 2: community mental health practices

Attitudes conducive to resilience by simply doing the washing up without rushing. The most important thing is not In the last ten years, neuroscience and to sit in the lotus position, but to learn to psychology research has identified devote at least twenty minutes a day to numerous attitudes conducive to calm observation, preferably continuously, resilience. In particular, the work of which is the minimum required to maintain Richard Davidson and Martin Seligman a psychological balance. has brought to light neurological virtues (Davidson’s terminology) or personal Compassion, love and tenderness: strengths (Seligman’s terminology) that also known as the compassion cluster, should be nurtured over time. According evoke the positive attachment which is to both researchers, our choice of attitudes vital to people’s emotional well-being. (healthy or unhealthy) can significantly This generates maximal plasticity when change the growth of specific neuronal expressed frequently and in a variety of networks which stimulate or undermine forms. In the same day one can show our resilience. This is not the place to love for a partner, affection for a dog, produce a full list of these attitudes, but benevolance towards colleagues. This the most beneficial in terms of positive repeat desire to ensure other people’s neuroplasticity are discussed below. well-being gradually shapes new neural networks like a river which carves out its Mindfulness: mindfulness comes top of bed over time. the list of beneficial attitudes associated with resilience. There is a general Gratitude: seeing the glass half full consensus that moments of silence and rather than half empty has a profound solitude experienced with a psychological effect on resilience. This does not mean posture of open-mindedness and calm constantly showing unbridled optimism, observation are vital to good mental but rather regular cognitive reframing health. In traditional societies, these which accentuates the positive aspects of moments formed an integral part of our a situation, thus countering human beings’ daily lives. In the era of modern technology natural tendancy to focus on threatening our life habits have been shaken up and or irritating details. these moments of centration, attention, and calm have been replaced with almost Forgiveness: recent studies in 30 constant interaction, often at a frenetic neuroscience have shown that resentment pace. These constant external sollicitations strongly activates the neural networks in translate into a marked reduction in the right prefrontal lobe, the target site for attention span, internal confusion, a negative feelings. This overstimulates the weakening of social connections, and amygdal, the cerebral structure responsible consequently reduced resilience. People for perceptions of fear and the physical often confuse mindfulness and formal reactions this provokes, which traps the meditation which can be off-putting. individual between an overwhelming Indeed, although meditation is one of desire to fight or flee. Overcoming the most visible practices in the field resentment requires forgiveness or at the of mindfulness, it is not the only one. very least resolving the conflict in question Mindfulness can also be achieved through in order to achive the state of internal a slow walk in the countryside, relaxing stability required to show resilience. in a hot bath with a scented candle, from the flow experienced when the boundaries Justice: from a very young age, around 6 of oneself dissolve in an intense period months old, most human beings already of creative or sporting activity, or even have a well-developed sense of justice and react strongly to any perceived The following aspects should be given injustice, even if they are not the victim. particular consideration: Resilience is associated both with the mere • Training staff members in personal acknowledgement of unfair situations resilience strategies for their own personal and the actions taken to resolve them. benefit (to counter the risk of burnout). Taking action consolidates the conviction • Using the notions of resilience, in particular that there is a deep-rooted, meaningful the 5Cs, in order to modify working collective connection and this sense of environments and make them more something greater than onself nourishes conducive to resilience. resilience. When it is impossible to directly • Train the response teams in the collective influence an injustice, acknowledging it, application of these concepts to vulnerable forming a positive altruistic intention for and marginalised populations in order to those affected, and considering what jointly foster resilience and empowerment. measures could be taken in the longer • Using the notions of resilience, in particular term to overcome it, constitutes the most the 5Cs, in order to modify working adequate response. environments and make them more conducive to resilience. Temperence: in terms of resilience, • These principles could also be used as a temperance refers to a sense of balance, framework for drawing up health policies rather than of sobriety. Enjoying life’s with a view to developing psychological pleasures but without overindulging and resilience. maintaining healthy work-life boundaries, reflect the meaning of temperance in this context. Recovery

Emotional regulation When we hear the word «recovery» we immediately think about «getting better». We John Kabat-Zinn is an authority on think about how flu symptoms disappear emotional regulation: in short he and allow us to return to our normal daily recommends cognitive strategies which lives. In the field of mental health, the notion interrupt reflex reactions and replace of recovery is somewhat different. The them with more thoughtful responses. symptoms have a huge impact on people’s Reflex reactions induce the secretion of lives. Treating them requires much more cortisol, causing pathological behaviours than a few days in bed. They can damage and leading to exhaustion, whereas a people’s relationships with their partners, thoughtful response to a crisis or stress force them to change their career and cause corresponds to mindfulness and restores them to lose friends. Very often this leads CMH calm. them to consider their life, values, objectives Part 2 and future perspectives from a new angle. In mental health, recovery is a process of Avenues for applying the resilience transformation. It is a journey towards a concept as part of HI’s activities genuinely meaningful life. This journey is In the light of HI’s intervention philosophy, unique and personal to each individual. It is i.e.: not about returning to the point of departure, 1. An approach based on positive mental to «normality». This is impossible because health rather than psychopathology the disorder has changed everything. It 2. A focus on individual and collective is about rebuilding a new life. It is even empowerment and possible that this life will prove to be more 3. The importance placed on capacity- interesting than the impairment-free one building which preceded it! ... it would appear that the concept of resilience as presented at the workshop The recovery movement began in the would be a natural fit with our ongoing second half of the 1980s. At this time, in programmes. the United States, service users began Part 2: community mental health practices

to speak about their experience and talk The second central tenet of recovery is the about the recovery process (Lovejoy 1984, assertion that the people concerned have 1982; P. E. Deegan 1988; P. Deegan control over their recovery: it is always a 1996; Leete 1989, 1987; Unzicker 1989). person who recovers, not professionals They talked about hope, acceptance, who «recover» someone. It is therefore reconstruction, a positive self-image, the person who needs to make choices engagement in the life of society. For for themselves. For a long time it was Patricia Deegan, one of the movement’s considered that people with mental health leading figures in this “Recovery is a disorders were unable to manage their process. It is a way of life. It is an attitude own lives and make decisions about their and a way of approaching the day’s future. But this is not the case. Nor is it challenges ... Recovery is marked by possible to imagine someone other than an ever-deepening acceptance of our the person concerned making decisions limitations. But now, rather than being an about their recovery goals. Nobody knows occasion for despair, we find our personal better than the person themselves. This limitations are the ground from which does not mean that the person does springs our own unique possibilities. not need support and guidance on the This is the paradox of recovery ... that in way and help with the decision-making accepting what we cannot do or be, we process. However, in the end the choice begin to discover what we can be and must always be theirs. what we can do.”

Recovery is built around two key ideas: Definitions hope and choice. Currently, as the recovery concept is being developed, a Out of these first writings by users, large corpus of scientific studies have more formal definitions of recovery were already demonstrated that it is possible developed. The best known is that of to get better, that many people with William Anthony at the Boston University severe mental illness can life a normal Centre for Psychiatric Rehabilitation: life with minimal support from health «Recovery is a deeply personal, unique professionals and that a non-negligeable process of changing one’s attitudes, percentage will actually no longer values, feelings, goals, skills and/or roles. meet the diagnostic criteria and will, It is a way of living a satisfying, hopeful, 32 in fine, be considered to be no longer and contributing life even with limitations ill. However, too many professionals caused by the illness. Recovery involves still continue to present disorders as the development of new meaning and systematically chronic and with little hope purpose in one’s life as one grows of improvement, even stating that they beyond the catastrophic effects of will inevitably deteriorate. The recovery mental illness.» (Anthony 1993). Another movement asserts loudly and clearly conceptualisation of recovery is currently that it is possible to get better, that in widespread use: the CHIME factors there is hope. But getting better in this (Leamy et al. 2011). Based on interviews context does not necessarily mean that with users, it highlights five aspects of the the person’s symptoms will disappear. recovery process. What is does mean is that it is possible to find one’s place alongside others to • Connectedness live a worthwhile and meaningful life, to Connectedness is the feeling of being make choices for yourself, and to involve connected with other people. We know yourself in a socially valuable role, even if that solitude and isolation have an impact the disorder persists. on both people’s physical and mental health, which is why connectedness is so a goal. This is different for each person, important. Relationships with family and but everybody needs to feel this. For friends are one way of feeling connected. some people, this might mean working or This feeling can also come from support volunteering, for others it might be going from people who have had a similar for a walk, doing the shopping or calling a experience (peer support), as well as friend. Meaning and objectives are defined from health professionals listening to and individually. These are not necessarily valuing people. Some people also place major, life-changing events. They just need great importance on relationships with to have meaning for the person concerned. their neighbours or members of the local For many people, it is also important that community. Generally speaking, spending they find meaning in their psychological time with supportive people and accepting or traumatic experience. Living with a people as they are, with no judgement, can disorder can be perceived as a spiritual genuinely help. experience, a medical problem, a response to stress, and many other things. It is the • Hope person themselves who will find their own Hope is particularly important for response. recovery and well-being. When a person experiences distress and dispair, they • Empowerment need to know that things can get better. There are numerous definitions of Relationships help to keep hope alive and empowerment, but they all refer to choices prevent feelings of impotence and despair. and the control one has over one’s own These relationships can be with family, life. A person can be empowered by being friends, peers or professionals. However, involved in the decision-making process some relationships do not build hope and regarding their treatment and care, which may even tear it down. If people say to also involves supporting them in making you «you will probably never work again» choices where the outcomes are not 100% or «you’re ill you can’t do that», this clearly certain (such as coming off medication). takes away hope. These sorts of remarks are entirely unjustified. There is now much Empowerment is also linked to a feeling scientific proof that people can get better of control and the ability to cope with and improve their quality of life regardless day-to-day responsibilities regarding their of their diagnosis. health and well-being. This also involves knowing when to ask for help. People who • Identity are positive about their recovery process, Developing or rediscovering an identity have almost certainly been through other than that of a «patient» is an an empowerment process, they have important part of the recovery process. For identified their strengths and built on this CMH some, this means returning to previously foundation. Part 2 held roles in society, such as a job. For others the aim is to develop a new identity. Many people say they need to feel that Recovery-focused services they have an identity other than that of a patient. This is true for everybody, we The recovery movement also positioned all have a distinct identity made up of itself in relation to psychosocial different components influenced by our rehabilitation, which dominates the gender, culture, beliefs, interests, and organisation of mental health care. The values. Once again, relationships with development of rehabilitation services people who consider the person as an brought with it numerous advantages individual in their own right are a key compared to the organisation of mental factor. health care in asylums. Focused on the inclusion of people in everyday life by • Meaning focusing on their strengths and developing Having a meaningful life simply means their skills, these services have supported having a reason to get up in the morning, the idea that people with mental health Part 2: community mental health practices

disorders can play a valuable role in capacities. It offers very different forms society. Furthermore, many rehabilitation of care management from one person to programmes have a proven track record another. The professionals adapt to the and are still widely used (psychoeducation, person not the other way around. intensive support in the community, job assistance, sheltered housing etc.) • Community resources (Bond and Campbell 2008). However, Support from the person’s environment the recovery movement considered should be identified and involved in psychosocial rehabilitation to be too the planning and provision of services, focused on services to the detriment of and promoting their inclusion in the people. The objectives were too often community. This involves referring them determined by professionals and not to peer-support groups, proactive support enough by the users themselves. The role into employment, links with activities of the users themselves in the recovery outside of mental health etc. process has not been sufficiently placed at the forefront. The professionals remain • User participation the ones who know best, even though it A team focused on recovery allows users is always the person who recovers, never to control the organisation and planning of professionals who “recover” people. their assistance and care. A team focused on recovery arranges for opportunities This leads us to question the role for users to influence how the service professionals play in supporting the operates and how care policy is defined. recovery process. If people are responsible for their own recovery, what are health In addition to the widely-used psychosocial professionals supposed to do? The key is rehabilitation tools, other support tools to offer people genuine, explicit choices, have been specifically developed to to offer them real opportunities in terms support the recovery process, often by of their plans, social engagement - not users themselves: only in dead-end roles - and finally, to • CommonGround4 is a web application believe in their chances of succeeding in which helps people to prepare their their undertakings. That said, research has consultations with their psychiatrist or been conducted in this area to identify the care team in order to determine together characteristics of recovery-focused services the best treatment and support. It is a 34 (Williams et al. 2012; Mancini 2006). psychoeducation tool, which provides Several recurrent aspects have emerged: users with relevant information on disorders and treatments; a self- • Integrated services management tool which allows users to A team focused on recovery should be able self-assess their situation from day to to offer a wide range of assistance and day and to act accordingly; and a shared- care (including basic care) using different decision making tool as it supports the methods (individual, group, peers): general user in the event of any negotiation with medical care, medication, diet, hygiene the physician regarding their treatment. and clothing, employment/training, daily • The Wellness Recovery Action Plan activities, family support, treatment of (WRAP)5 is a personalised well-being addiction, psychotherapy, trauma care, and recovery process, based on the well-being, welfare, other rights. principles of empowerment. It can be used to get better, stay better, or change • Individual care management your life as you see fit. It is a set of tools A team focused on recovery assesses the developed in 1997, by users and ex- person’s needs, preferences, strengths and users, who wanted to overcome their mental health problems to life their lives, fulfill their dreams and follow their plans. This set of tools is used as part of a peer support group, based on mutual support and sharing experiences. It is facilitated by two trained users, who have used the tool in their own recovery pathway. The WRAP is now an internationally recognised tool which has been assessed and studied (Copeland 2002; Fukui et al. 2011; Cook et al. 2012). • Refocus6 is a training programme for caregivers focusing on the working relationship between caregivers and service users. Staff are trained to identify and understand the values and preferences of users, to support and asess users’ strengths, and to support users in identifying goals (Slade et al. 2011).

CMH Part 2

1. Translator’s note, free translation from French source 2. Translator’s note, free translation from French source 3. In basic terms a disability (or handicap) is a disadavantage in terms of weight, distance or points imposed on the person with the greatest chance of winning (as used in golf, horse racing or sailing). 4. https://www.patdeegan.com/commonground 5. http://mentalhealthrecovery.com/ 6. http://www.researchintorecovery.com/refocus Part 3: challenges, stakes and perspectives

1. Challenges and when they return to their community the person’s social resources have often A number of challenges were raised been eroded, generating social exclusion. during the discussions between seminar participants. These were related both to the Many participants also raised the lack of contexts in which the different projects are proper mental health policies in numerous deployed and to HI’s positioning on mental countries, which results in a lack of health projects. investment in mental health services at all levels.

The context Poor ownership of the There are numerous problems, but they framework document on generally all revolve around the same issue: mental health the lack of resources. As described in the first part of this document, specialist mental The seminar highlighted the lack of shared health resources are often concentrated guidelines for HI’s different mental health in large cities and specialist psychiatric projects. The concept of community institutions. Decentralised health centres mental health itself was not clear to most have very few resources. participants. Whilst many of them had their own vision of what community mental At each stage of the person’ care pathway health is, no shared vision emerged. This we can identify specific gaps: meant that there were a number of projects • Firstly, in the districts, there is nobody which could have been presented at the capable of diagnosing a psychiatric seminar but their managers did not see the disorder or even assessing potential connection with community mental health. severity with a view to referring the person Conversely, some of the projects which to a specialist service for confirmation. were presented only had a tenuous link People generally have to wait a very long with community mental health. There was time for a diagnosis. little consistency and coherence across the 36 • The districts also do not have any specialist different projects presented at the semainar. centres or mental health professionals (psychiatrists, psychologists) to whom In order to strengthen HI’s projects in the people likely to suffer from mental health mental health field and make them more disorders can be referred. The absence of coherent, it would be interesting to set out specialist health centres also complicates the principles and guidelines followed by HI access to medication and other therapies. in the area of mental health in an updated • Finally, for the people referred to a framework document. The stakes laid out in specialist service, usually a psychiatric the following paragraph should be discussed hospital in the country’s capital, there to establish these principles and guidelines. is a lack of resources for supporting the person’s return to their community after hospitalisation. When the referral process does work in one direction, it also needs to work in the opposite direction. Furthermore, there remain high levels of stigma around mental health disorders, 2. Stakes and perspectives disorders, even severe ones, it is important not to simply automatically refer these people to specialist services and consider Disability and mental health they cannot be helped via a social support disorders mechanism in the community. It is important to consider, following on from the contiuum Many projects are not specifically focused of theories set out above, that even if people on mental health disorders, or even on with severe mental illness require specialist improving the mental health of vulnerable care, they may also require social support categories of the population. Most in the community, peer-support, or job projects are primarily focused on physical assistance. (impairment, chronic disease etc) or social (gender-related issues, domestic violence It would be wise to put into place etc.) issues and have a psychosocial awareness-raising and training tools dimension. These difficulties can cause which are accessible to HI workers and our mental health disorders or impact people’s partners. This training should include an mental health. However, it became clear understanding of mental health symptoms through the semainar that HI does not have but not of mental illness. The key here is any guidelines on the mental health issues not the ability to diagnose a disorder. A experienced by people with disabilities or on diagnosis is useful when determining a how to manage these. What psychological medical intervention. Here, the objective is problems do amputees face? What type of to support workers to ensure they adopt care management has been shown to be the right attitudes towards people with successful in this type of situation? mental health disorders, so they can better understand what these people are going HI needs to specifically explore the through, and know how to behave when potential psychological consequences of the person shows signs of a disorder, how the impairments and chronic diseases it to create a secure context, etc. It would be most commonly encounters. In addition to interesting to work on the right attitudes identifying the most common disorders in to adopt when faced with people living the literature and how these are managed, with anxiety, delusions or hallucinations, this type of approach could lead to the depression or apathy, post-traumatic stress delivery of training courses for actors in the or a highly-stigmatised trauma. In addition it field. would be useful to work on people’s ability to identify the warning signs which require referral to a specialist. Do all projects have a psychosocial dimension? Beneficiary involvement in Many of HI’s projects are likely to have their care pathway a psychosocial dimension. People made vulnerable due to violence, natural disasters, Beneficiary involvement is one of HI’s key social exclusion or health problems are likely concerns. Over the course of the seminar, all to develop mental health disorders. It is very participants mentioned this as a key feature unlikely that a sub-project on the care- of HI’s positioning. However, the distinction CMH management of mental health disorders between beneficiary involvement and Part 3 could be added to all HI’s projects. However, social participation is not always clear. one realistic and relevant objective would Social participation is found in a variety be to raise the awareness of the people of forms in HI’s projects: designing and involved in a project of how to behave implementing projects in collaboration with towards these people so they do not feel local managers, supporting people with rejected and stigmatised and that they disabilities to help them find a place in their benefit from the same services as everyone community, or supporting the organisation else. When faced with mental health of groups of people to claim and contest. Part 3: challenges, stakes and perspectives

However, beneficiary involvement also refers Furthermore, HI could also equip its workers to something else: it is about supporting with tools to explore the context in which people to make their own choices and the person finds themselves, their resources, construct their own objectives, their own the stigma and barriers they face, the vision of the situation. peopme they depend on, etc. There are also specific tools to help a person to specify their In order to do this, project workers need own objectives, the issues that are important to ensure that the people supported can to them, and from this, build a project and actively participate in decision making set goals. These types of tools already exist throughout all stages of the support in the field of psychosocial rehabilitation process. The project workers need to and recovery. These tools make it possible adopt an attitude of «know-not», a humble to work as closely as possible to the reality attitude, focused on listening to the person of the person’s situation and helps project and their vision of the situation. This workers to avoid suggesting what they means the first objective is not to explain believe are the best solutions, without taking to beneficiaries the situation they are in into account the issues the person is facing. and the attitudes they should adopt - even when there are things they objectively need to know about their disorder - but Mental health projcts based to support them to make meaningful decisions for themselves. Given the on community-based interactions observed at the seminar, this rehabilitation is not obvious for everybody. Adopting these attitudes is naturally considered to Numerous international recommendations be important, but is not easy to put into encourange the inclusion of mental health practice. services in mainstream services, such as primary health care services or community- It might be appropriate to include based rehabilitation services, not only to components in the training courses offered reduce stigma, but also to compensate to HI workers to help them develop a for the stark lack of resources in certain «patient-focused attitude». Carl Rogers countries. In terms of HI’s experience, it has spoke about three fundamental attitudes. extensively used a range of support tools for The first attitude is «congruence» and people with disabilities: community-based concerns the caregiver’s ability to rehabilitation (CBR), personalised social correctly connect with the complex support (PSS) and community workers, both feelings, thoughts and attitudes they voluntary and salaried workers. These tools experience whilst keeping track of the can be used to increase people’s involvement thoughts and feelings of the person they in their care pathway, as mentioned above. are supporting. The second attitude is the «unconditional positive regard», i.e. HI should develop mental health projects 38 total and unconditional acceptance of the using the CBR and PSS tools. This is already person being supported. The third attitude the case in a number of projects. This option is «empathic understanding», trying is supported by the scientific literature which to understand the world of the person has demonstrated their effectiveness and supported without being overwhelmed relevance. In practical terms, using these by it. Practically speaking, the project intervention methods will require a certain worker will check their understanding of adaptation. For example, PSS support plans the person’s world by summarising and may include specific systems for organising reformulating etc. HI’s practice could be a coordinated reaction in crisis episodes or inspired by this. relapses. Furthermore, there are specific mental health guidelines in the WHO’s CBR Updating HI’s mental health guide. The advantage of this option is that it also supports HI’s stance on mental health: a policy social vision of mental health disorders focused on improving people’s social participation. The various components discussed herein, no doubt along with other aspects of note, could be summarised and thought through as part of an update of the 2011 framework What about interventions in document. The latter could contain: emergency settings? • HI’s vision of mental health and psychsocial support projects, which, if we Community mental health also has a role take the components from the second part to play in emergency situations. The use of is: a social vision of psychological disorders standard tools such as psychological first and/or distress, involving beneficiaries in aid is worth considering. These are often their care pathway, with a clear goal of used systematically and by people with little ensuring their social participation. training (Zimmermann 2016). • A reaffirmation of what community mental health is from HI’s perspective, bearing in In emergency situations, HI could also move mind that this is largely developed in the into rehabilitation in a second phase, following 2011 framework document. the crisis, whilst paying particular attention to • Choices in terms of the priority people already made vulnerable, in order to populations: people suffering from limit the impact of traumatic events. disorders and/or distress typically associated with other physical (disability) It would be wise to make a clear decision or social (detention, gender-based violence on these types of issues, especially as very etc.) issues, people with moderate to few projects currently work in emergency severe mental disorders (pre-existing and/ settings, yet a number of the reference or exacerbated by the context in which documents and conceptual tools used HI is operating), people suffering distress have been developed based on emergency relating to the context (war, internal response expertise. conflicts, natural disasters, vulnerability) etc. • The intervention method, «stand-alone» Advocacy to promote robust project or integrated mental-health component. mental health policies • The tools to use (or not) depending on the contexts and issues identified: Most of the countries where HI operates peer support groups, individual or have no national mental health policy and group psychotherapy, psychoeducation, fail to invest in mental health services. HI psychological first aid etc. supports the deinstitutionalisation of mental • The minimum competence of mental health by developing networks of health, health and psychsocial support workers social and community professsionals and (knowledge, soft and hard skills). supporting coordination between them. HI • Priorities in terms of advocacy. supports the development of community- based services. CMH It would be advisable to work off these Part 3 basic principles to develop a vision of the organisation of mental health care, its requisite components and how these work together. This could be based on the service pyramid, adapted for use in the Palestine project, for example. This would allow us to present a coherent vision of the desired care system to the relevant authorities. Appendices

1. Seminar Terms of Reference Today, with more than 30 years’ experience in the field working in constantly changing and Programme socio-political contexts, the mental health and psychsocial support sector wants to TECHNICAL SEMINAR AC4 rethink its intervention methods in order to COMMUNITY MENTAL HEALTH best meet the needs of the populations we Date: 7 - 9 December 2017 support. Location: Kigali, Rwanda

Division: Lead: Technical Resources Division, Prevention and Health Unit, Mental Health Why hold this seminar? and Psychosocial Support Sector Collaboration: Inclusion Unit - Social In many countries, people living with Inclusion Sector; Impact, Monitoring and a psychosocial disability suffer from Evaluation Unit discrimination and stigma linked to the Location: Rwanda expression of their psychological suffering or Seminar title: Community Mental Health psychopathological disorder. These people Duration: 3 days are sometimes the victims of violence, abuse Dates : 7 - 9 December 201 and exploitation, as the representations associated with psychological suffering and mental health disorders are extremely Introduction negative.

Receiving little or no support, these people Mental health problems are commonplace are often isolated and are often unable to and affect more than one in four people cope with the difficulties they encounter in worldwide. This represents 10% of their daily life and in being recognised as the global burden of disease. They are actors in society in their own right. They do responsible for a quarter of disabilities and not necessarily have access to community result from a complex range of personal, services or aid and development and social and environmental situations. These mutual support mechanisms which help figures are even higher in emergency them to fully participate in society. This is response settings. the situation we encounter in many of the countries where HI operates. HI has been working in this area since the 1990s. Our actions aim to prevent On the one hand, we see a lack of mental mental health disorders, provide care and health services or very poor quality services, support towards social inclusion, fight the concentrated in the country’s capital and in stigma around mental health and disabling private or central hospitals. There are very situations, and promote positive mental few mental health professionals and they health. All these actions are implemented do not always have training and supervision using multi-disciplinary, participative, available to them to improve the quality of community approaches which take care to their services. coordinate the different actors involved.

On the other hand, people with mental Our interventions have always targeted health issues and their familes do not 40 vulnerable and isolated populations such always reach out to existing health services, as the victims of war or genocide, orphans, for a number of reasons. First of all, the female victims of violence, people with fear people seeking support have of being mental, sensory or intellectual disabilities, stigmatised and labelled by members of the and people living with disabling diseases. community. Then there is the difficulty the person themselves or their family members links with other areas of activity (social, have in acknowledging the existence of economic, justice, education etc.) to mental health issues and the need for provide comprehensive care management external support. Some people will prefer for the person which meets all of their other forms of assistance and will turn needs. to traditional healers or other alternative therapies aligned with their beliefs and convictions. Seminar objectives

How can we help people access quality HI’s has a a wealth of experience in the mental health services given the challenges community mental health sector which associated with access to services? How varies widely in terms of context (emergency can we reinforce solidarity mechanisms to response, post-emergency, chronic crisis, support people with mental health issues to development), socio-cultural dynamics, the be actors in society in their own right and problems met in the mental health sector, have their basic rights upheld? How can we the project objectives, duration, how they are engage decision-makers, service providers managed and the people involved etc. and the community in investigating innovative and tangible practices and It now appears important to consolidate strategies to promote positive mental health, and formalise this knowledge and expertise prevention and support for people with in community mental health, and to mental health problems. enhance this with the experiences of other organisations to build our expertise in this One of the approaches favoured by sector. Handicap International for meeting mental health challenges is the community-based approach. MAIN OBJECTIVES Discuss and capitalise on this approach This approach is based on theoretical to consolidate our expertise internally guidelines from clinical psychology, with the aim of improving the quality of social anthropology and inclusive local our interventions whether in emergency development. It aims to reconnect the response, post-crisis or development person with themselves and others by: contexts. • Empowering the person living with a mental health issue SPECIFIC OBJECTIVES • Mobilising community actors to engage in • Share and collect good practices from the mental health sector different community mental health models • Implementing actions to mobilise aid and • Ensure a shared understanding of development mechanisms and community community mental health in order to living ensure the coherence of our actions • Define a work methodology to formalise The principles behind this approach are and develop expertise in community generally as follows: mental health • A rights-based intervention in order to:

• Give a voice to people living with mental health issues • Uphold their right to make decisions about Expected results their own lives • Involve «mental health users» in all the • The participants understand the different projects affecting them community mental health approaches CMH • Facilitate full social participation (the theoretical guidelines and practical Appendices • An intervention that is sensitive to social, implementation) cultural, anthopological and traditional • The participants know about the different dynamics. experiences of community mental health • An intervention which aims to forge at HI Appendices

• The participants discuss and share good Detailed programme practices in building a community-based mental health intervention THURSDAY • The participants think about a Place: Plenary – main room methodology for community-based interventions based on the experiences 08.30 - 09.00 Reception and Registration and discussions at the seminar 09.00 - 10.15 Seminar Opening and Introduction Deliverable Session moderator: Maximilien, Mental Health TA Speakers: Jean-François Michel, Field Programme Director (to be confirmed) • A document on community-based Joëlle Gustin, HI Luxembourg (to be confirmed) interventions 10.15 - 10.30 Seminar Introduction: Objectives and programme, introduction of guest experts Speaker: Maximilien, Mental Health TA

10.30 - 11.00 Health break

11.00 - 12.00 Plenary Round Table 1 – CONCEPTS Speakers: Maximilien, François

12.00 - 12.30 Theory Wrap-Up: Mental Health TA Speakers: Maximilien, François

12.30 - 14.00 Lunch

14.00 - 15.30 Plenary round table 2 – PRACTICES COUNTRY presentations: (Rwanda, Haiti, Bolivia, Cuba, Colombia, subject to modifications)

15.30 - 16.00 Health break

16.00 - 17.00 Round Table, Presentations and Discussions (continued)

17.00 - 18.00 Presentation 1: CAPITALISATION tool: the Group at HI COUNTRY presentations: (Togo, Madagascar, Sierra Leone, South Sudan) Speaker: Aude Bosson with collaboration from the Mental Health TA Programme Coordinator: «Touching Minds Raising Dignity»

42 FRIDAY 2. Bibliography Place: Plenary – main room Aggarwal, Neil Krishan, Madhumitha Balaji, 09.00 - 10.30 Presentation 2: Resilience at Shuba Kumar, Rani Mohanraj, Atif Rahman, community level Helena Verdeli, Ricardo Araya, M. J. D. Speaker: Guest expert, Rachel Thibeault Jordans, Neerja Chowdhary, and Vikram 10.30 - 11.00 Health break Patel. 2014. “Using Consumer Perspectives to Inform the Cultural Adaptation of 11.00 - 11.45 Workshop N°1 Psychological Treatments for Depression: Building resilience A Mixed Methods Study from South A: in emergency settings B: in development contexts Asia.” Journal of Affective Disorders 163 C: for the caregivers themselves (CARE FOR (July): 88–101. https://doi.org/10.1016/j. CAREGIVERS) jad.2014.03.036.

11.45 -12.30 feedback using cartesian graph Anthony, William A. 1993. “Recovery from By three representatives A, B and C, facilitated Mental Illness: The Guiding Vision of the by Rachel T. Mental Health Service System in the 1990s.” Psychosocial Rehabilitation Journal 16 (4): 11. 12.30 - 14;00 Lunch Araya, Ricardo, Graciela Rojas, Rosemarie 14.00 - 15.30 Presentation 3: The role of the Fritsch, Jorge Gaete, Maritza Rojas, Greg user and the recovery model Simon, and Tim J. Peters. 2003. “Treating Speaker: Guest expert, François Wyngaerden Depression in Primary Care in Low-Income 15.30 - 16.00 Health break Women in Santiago, Chile: A Randomised Controlled Trial.” The Lancet 361 (9362): 16.00 - 16.45 Workshop N°2 995–1000. Supporting recovery A: at individual level Bolton, Paul, Judith Bass, Richard B: at community level Neugebauer, Helen Verdeli, Kathleen F. C: within mental health policies (how can this Clougherty, Priya Wickramaratne, Liesbeth aspect be included?) Speelman, Lincoln Ndogoni, and Myrna 16.45 - 17.30 feedback Weissman. 2003. “Group Interpersonal By representatives from the three groups Psychotherapy for Depression in Rural Uganda: A Randomized Controlled Trial.” 17.30-18.00 Evaluation Jama 289 (23): 3117–3124. By representatives from the three groups Speaker: Laetitia Frémont, Knowledge Management Bond, G.R., and K. Campbell. 2008. “Evidence-Based Practices for Individuals SATURDAY with Severe Mental Illness.” Journal of Place: Plenary – main room Rehabilitation 74 (2): 33–44. Burns, T., M. Knapp, J. Catty, A. Healey, 09.00 - 10.30 workshop n°3 (creative) towards J. Henderson, H. Watt, and C. Wright. a common foundation 2001. “Home Treatment for Mental Health 10.30 - 11.00 Health break Problems: A Systematic Review.” Health Technology Assessment 5 (15): i-129. 11.00 - 12.30 Workshop N°4 What will I bring back to my CBM. 2008a. “Guide de Santé Mentale project? Communautaire.”

12.30 - 14h00 Lunch ———. 2008b. “Politique de Santé Mentale Communautaire.” 14.00 - 14.45 feedback from workshops 3 and 4 Chatterjee, Sudipto, Morven Leese, Mirja By representatives from the three groups CMH Koschorke, Paul McCrone, Smita Naik, Sujit Appendices 14.45 - 16.00 WRAP-UP and CONCLUSIONS John, Hamid Dabholkar, Kimberley Goldsmith, Speakers: Mental Health TA and Guest Experts Madhumitha Balaji, and Mathew Varghese. IMMEDIATE EVALUATION BY PARTICIPANTS: 2011. “Collaborative Community Based https://www.sphinxonline.com Care for People and Their Families Living Appendices

with Schizophrenia in India: Protocol for a Monitoring, Reducing and Eliminating Randomised Controlled Trial.” Trials 12 (1): 12. Uncomfortable or Dangerous Physical Symptoms and Emotional Feelings.” Chatterjee, Sudipto, Vikram Patel, Occupational Therapy in Mental Health 17 Achira Chatterjee, and Helen A. Weiss. (3–4): 127–150. 2003. “Evaluation of a Community- Based Rehabilitation Model for Chronic Coppock, Vicki, and Bob Dunn. 2009. Schizophrenia in Rural India.” The British Understanding Social Work Practice in Journal of Psychiatry 182 (1): 57–62. https:// Mental Health. SAGE. doi.org/10.1192/bjp.182.1.57. Deegan, Patricia. 1996. “Recovery as Chien, Wai-Tong, Sally WC Chan, and David a Journey of the Heart.” Psychiatric R. Thompson. 2006. “Effects of a Mutual Rehabilitation Journal 19 (3): 91. Support Group for Families of Chinese Deegan, Patricia E. 1988. “Recovery: People with Schizophrenia: 18-Month The Lived Experience of Rehabilitation.” Follow-Up.” The British Journal of Psychiatry Psychosocial Rehabilitation Journal 11 (4): 189 (1): 41–49. 11. Chisholm, Daniel, Sarah James, K. Sekar, K. Dias, Amit, Michael E. Dewey, Jean D’Souza, Kishore Kumar, R. Srinivasa Murthy, KHALID Rajesh Dhume, Dilip D. Motghare, K. S. Shaji, Saeed, and MALIK Mubbashar. 2000. Rajiv Menon, Martin Prince, and Vikram “Integration of Mental Health Care into Patel. 2008. “The Effectiveness of a Home Primary Care: Demonstration Cost–outcome Care Program for Supporting Caregivers Study in India and Pakistan.” The British of Persons with Dementia in Developing Journal of Psychiatry 176 (6): 581–588. Countries: A Randomised Controlled Trial Chisholm, D., and G Thornicroft. 2007. from Goa, India.” PloS One 3 (6): e2333. “Scale up Services for Mental Disorders: Drapeau, Aline, Alain Marchand, and A Call for Action.” The Lancet 370 (9594): Dominic Beaulieu-Prévost. 2012. 1241–52. https://doi.org/10.1016/S0140- “Epidemiology of Psychological Distress.” In 6736(07)61242-2. Mental Illnesses-Understanding, Prediction Cohen, Alex, Julian Eaton, Birgit Radtke, and Control. InTech. Christina George, Bro Victor Manuel, Eaton, Julian, and Ahamefula O. Agomoh. Mary De Silva, and Vikram Patel. 2011. 2008. “Developing Mental Health Services “Three Models of Community Mental in Nigeria.” Social Psychiatry and Psychiatric Health Services in Low-Income Countries.” Epidemiology 43 (7): 552–558. International Journal of Mental Health Eaton, Julian, Layla McCay, Maya Semrau, Systems 5 (1): 3. Sudipto Chatterjee, Florence Baingana, Collectif des 39. 2011. “Déclaration de Lyon : Ricardo Araya, Christina Ntulo, Graham Quand La Mondialisation Onous Rend Fous, Thornicroft, and Shekhar Saxena. 2011. Pour Une Écologie Sociale.” In . Lyon. “Scale up of Services for Mental Health in Cook, Judith A., Mary Ellen Copeland, Low-Income and Middle-Income Countries.” Marie M. Hamilton, Jessica A. Jonikas, The Lancet 378 (9802): 1592–1603. Lisa A. Razzano, Carol B. Floyd, Walter B. Evans, P. J., P. Zinkin, T. Harpham, and G. Hudson, Rachel T. Macfarlane, and Dennis Chaudury. 2001. “Evaluation of Medical D. Grey. 2009. “Initial Outcomes of a Mental Rehabilitation in Community Based 44 Illness Self-Management Program Based Rehabilitation.” Social Science & Medicine on Wellness Recovery Action Planning.” (1982) 53 (3): 333–348. Psychiatric Services 60 (2): 246–249. Fougeyrollas, Patrick, René Cloutier, Hélène Copeland, Mary Ellen. 2002. “Wellness Bergeron, Ginette St-Michel, Jacques Côté, Recovery Action Plan: A System for Marcel Côté, Normand Boucher, Kathia Roy, and Marie-Blanche Rémillard. 1998. ———. 2009d. “Les Groupes de Parole Classification Québécoise: Processus de de Soignants de Type Balint En Algérie. Production Du Handicap. Québec RIPPH/ Docume de Capitalisation.” SCCIDIH,. ———. 2009e. “Accompagnement Social Fukui, Sadaaki, Vincent R. Starnino, Mariscal Personnalisé : Réflexions, Méthode et Susana, Lori J. Davidson, Karen Cook, Outils D’une Approche En Travail Social de Charles A. Rapp, and Elizabeth A. Gowdy. Proximité.” 2011. “Effect of Wellness Recovery Action ———. 2010a. “Conditions de Vie Carcérale Plan (WRAP) Participation on Psychiatric et Détresse Psychologique Des Personnes Symptoms, Sense of Hope, and Recovery.” Détenues. Etat Des Lieux Dans Les Psychiatric Rehabilitation Journal 34 (3): 214. Prisons de Vatomandry et d’Antanimora À Gilmour, Heather. 2014. Santé Mentale Madagascar.” Positive et Maladie Mentale. Statistique ———. 2010b. “Enhanced Psychological Canada. Care Services for Palestinian Refugees Goldberg, David. 2000. “Distinguishing Children and Adolescents Living in Buss Mental Illness in Primary Care.” BMJ : British Camp.” Medical Journal 321 (7273): 1412. ———. 2010c. “Guide Méthodologique : Grant, Faren, Constance Guille, and Srijan Interventions Psychosociales et de Santé Sen. 2013. “Well-Being and the Risk of Mentale En Contextes D’urgence et de Post- Depression under Stress.” PLoS One 8 (7): Crise.” e67395. ———. 2011a. “Impulser et Accompagner Guzman, Juan Rodriguez, and Andres Le Changement Dans Les Pouponnières Barkil-Oteo. 2017. “Connecting the World.” Algériennes.” Handicap International. Telemental Health in Resource-Limited ———. 2011b. “Document Cadre : Santé Global Settings, 217. Mentale En Contextes de Post-Crise et de Henderson, David C., Richard F. Mollica, Développement.” Svang Tor, James Lavelle, Melissa A. ———. 2012a. “Conditions de Vie Carcérale Culhane, and Doug Hayden. 2005. “Building et Détresse Psychologique Des Personnes Primary Care Practitioners’ Attitudes and Détenues.” Confidence in Mental Health Skills in a Post- Conflict Society: A Cambodian Example.” ———. 2012b. “Interventions The Journal of Nervous and Mental Disease Psychosociales En Milieu Carcéral.” 193 (8): 551–559. ———. 2012c. “La Représentation et HI. 2007. “Accompagnement À La Vie L’évaluation Du Handicap En Haïti.” Affective et Sexuelle. Guide Pratique Pour ———. 2012d. “Les Groupes de Parole En L’animation Des Groupes de Parole.” Prison, Guide de L’animateur.” ———. 2008. “Capitalization on the Logic of ———. 2012e. “Réunir Les Solitudes Intervention in the Field of Mental Health in L’exemple D’un Projet de Santé Mentale Palestinian Refugee Camps in Lebanon.” Communautaire Au Rwanda.” ———. 2009a. “Accompagner Les ———. 2012f. “Santé Mentale Traumatismes Individuels Par Le Retissage Communautaire et Violences Liées Au Genre Des Liens Sociaux et Communautaires. Dans La Province Ouest Du Rwanda.” Un Exemple D’approche En Santé Mentale ———. 2016. “Émergence et Structuration Communautaire Après Le Génocide Des de Groupes de Soutien de Personnes Vivant Tutsi Au Rwanda.” En Milieu Fermé Avec Des Problèmes de ———. 2009b. “Ancrer La Sensibilisation Santé Mentale Au Togo, Madagascar, Liban CMH Dans La Communauté.” et Soudan Du Sud.” Appendices ———. 2009c. “Le Groupe de Parole de ———. 2017a. “Les Groupes de Soutien En Mamans D’enfants Handapés Moteurs En Santé Mentale, De La Souffrance Individuelle Situation de Dépendance En Algérie.” Au Collectif D’usagers.” Appendices

———. 2017b. “Fiche de Synthèse : Santé 2007. “Empowerment of Women and Mental Mentale et Soutien Psychosocial (SMSPS).” Health Promotion: A Qualitative Study in Rural Maharashtra, India.” BMC Public Horwitz, Allan V. 2002. “Selecting Outcomes Health 7 (1): 225. for the Sociology of Mental Health: Issues of Measurement and Dimensionality.” Journal of Keyes, Corey LM. 2002. “The Mental Health Health and Social Behavior 43 (2): 143–253. Continuum: From Languishing to Flourishing in Life.” Journal of Health and Social ———. 2007. “Distinguishing Distress from Behavior, 207–222. Disorder as Psychological Outcomes of Stressful Social Arrangements.” Health: 11 ———. 2007. “Promoting and Protecting (3): 273–289. Mental Health as Flourishing: A Complementary Strategy for Improving ILO, Unesco, and WHO. 1994. “Réadaptation National Mental Health.” American À Base Communautaire (RBC) Pour et Avec Psychologist 62 (2): 95. Les Personnnes Handicapées: Point de Vue Commun.” Keyes, Corey LM, Satvinder S. Dhingra, and Eduardo J. Simoes. 2010. “Change in Level Jacob, K. S. 2001. “Community Care for of Positive Mental Health as a Predictor of People with Mental Disorders in Developing Future Risk of Mental Illness.” American Countries: Problems and Possible Solutions.” Journal of Public Health 100 (12): 2366– The British Journal of Psychiatry 178 2371. (4): 296–98. https://doi.org/10.1192/ bjp.178.4.296. Keyes, Corey LM, Daniel Eisenberg, Geraldine S. Perry, Shanta R. Dube, Kurt Jacob, K. S., P. Sharan, I. Mirza, M. Garrido- Kroenke, and Satvinder S. Dhingra. 2012. Cumbrera, Soraya Seedat, Jair Jesus Mari, “The Relationship of Level of Positive Mental V. Sreenivas, and Shekhar Saxena. 2007. Health with Current Mental Disorders in “Mental Health Systems in Countries: Where Predicting Suicidal Behavior and Academic Are We Now?” The Lancet 370 (9592): Impairment in College Students.” Journal of 1061–1077. American College Health 60 (2): 126–133. Jefee-Bahloul, Hussam, Andres Barkil- Keyes, Corey LM, and Eduardo J. Simoes. Oteo, and Eugene F. Augusterfer. 2017. 2012. “To Flourish or Not: Positive Mental Telemental Health in Resource-Limited Health and All-Cause Mortality.” American Global Settings. Oxford University Press. Journal of Public Health 102 (11): 2164– Jenkins, Rachel, David Kiima, Marx Okonji, 2172. Frank Njenga, James Kingora, and Sarah Khasnabis, Chapal, Karen Heinicke Motsch, Lock. 2010. “Integration of Mental Health Kamala Achu, Kathy Al Jubah, Svein into Primary Care and Community Health Brodtkorb, Philippe Chervin, Peter Coleridge, Working in Kenya: Context, Rationale, et al. 2010. CBR and Mental Health. World Coverage and Sustainability.” Mental Health Health Organization. https://www.ncbi.nlm. in Family Medicine 7 (1): 37. nih.gov/books/NBK310918/. Kakuma, Ritsuko, Harry Minas, Nadja van Killaspy, H. 2006. “From the Asylum to Ginneken, Mario R. Dal Poz, Keshav Desiraju, Community Care: Learning from Experience.” Jodi E. Morris, Shekhar Saxena, and Richard British Medical Bulletin 79–80 (1): 245–58. M. Scheffler. 2011. “Human Resources for Mental Health Care: Current Situation Lagerkvist, B. 1992. “Community-Based 46 and Strategies for Action.” The Lancet 378 Rehabilitation—outcome for the Disabled in (9803): 1654–1663. the Philippines and Zimbabwe.” Disability and Rehabilitation 14 (1): 44–50. Kermode, Michelle, Helen Herrman, Rajanikant Arole, Joshua White, Leamy, Mary, Victoria Bird, Clair Le Ramaswamy Premkumar, and Vikram Patel. Boutillier, Julie Williams, and Mike Slade. 2011. “Conceptual Framework for Personal Auprès D’enfants Palestiniens Réfugiés Recovery in Mental Health: Systematic Au Liban.” Revue Développement Humain, Review and Narrative Synthesis.” The Handicap et Changement Social, 41. British Journal of Psychiatry 199 (6): Malone, D., S. Marriott, G. Newton-Howes, S. 445–452. Simmonds, and P. Tyrer. 2007. “Community Leete, Esso. 1987. “The Treatment of Mental Health Teams (CMHTs) for People Schizophrenia: A Patient’s Perspective.” with Severe Mental Illnesses and Disordered Psychiatric Services 38 (5): 486–491. Personality.” Cochrane Database of Systematic Reviews, no. 3. ———. 1989. “How I Perceive and Manage My Illness.” Schizophrenia Bulletin 15 (2): Mancini, A. D. 2006. “Can Recovery 197. Orientation Inform the Implementation of Evidence-Based Practices.” In 114th Annual Li, Zheng, and David Arthur. 2005. “Family Convention for the American Psychological Education for People with Schizophrenia in Association. Beijing, China: Randomised Controlled Trial.” The British Journal of Psychiatry 187 (4): Marshall, M., and A. Lockwood. 2011. 339–345. “Assertive Community Treatment for People with Severe Mental Disorders.” Lopez, Alan D. 2006. Global Burden of Cochrane Database of Systematic Reviews, Disease and Risk Factors. World Bank no. 4. https://doi.org/10.1002/14651858. Publications. CD001089.pub2. Lovejoy, Marcia. 1982. “Expectations and the Menil, Victoria de, and Chris Underhill. Recovery Process.” Schizophrenia Bulletin 8 2010. “Putting the Community Back into (4): 605–609. Community Mental Health: The Role of the ———. 1984. “Recovery from Schizophrenia: Community Worker.” A Personal Odyssey.” Psychiatric Services Mierlo, Bibiane van. 2012. “Community 35 (8): 809–812. Systems Strengthening in Afghanistan: A Lund, Crick, Mark Tomlinson, Mary De Silva, Way to Reduce Domestic Violence and to Abebaw Fekadu, Rahul Shidhaye, Mark Reinforce Women’s Agency.” Intervention 10 Jordans, Inge Petersen, Arvin Bhana, Fred (2): 134–145. Kigozi, and Martin Prince. 2012. “PRIME: Mooren, Trudy, Kaz de Jong, Rolf J. Kleber, A Programme to Reduce the Treatment and Jadranka Ruvic. 2003. “The Efficacy Gap for Mental Disorders in Five Low-and of a Mental Health Program in Bosnia- Middle-Income Countries.” PLoS Medicine 9 Herzegovina: Impact on Coping and General (12): e1001359. Health.” Journal of Clinical Psychology 59 (1): Lundgren-Lindquist, B., and L. A. Nordholm. 57–69. 1996. “The Impact of Community-Based Mueser, Kim T., William C. Torrey, David Rehabilitation as Perceived by Disabled Lynde, Patricia Singer, and Robert E. Drake. People in a Village in Botswana.” Disability 2003. “Implementing Evidence-Based and Rehabilitation 18 (7): 329–334. Practices for People with Severe Mental Maamari, Sophia, and Guillaume Pégon. Illness.” Behavior Modification 27 (3): 2012. “Les Relations D’interdépendance 387–411. Par Lesquelles on Est Soigné: L’exemple Du Mueser, K.T., G.R. Bond, R.E. Drake, and Dispositif de Santé Mentale Soutenu Par S.G. Resnick. 1998. “Models of Community Handicap International Auprès D’enfants Care for Severe Mental Illness: A Review Palestiniens Réfugiés Au Liban.” Revue of Research on Case Management.” Développement Humain, Handicap et Schizophrenia Bulletin 24 (1): 37–74. Changement Social, 41. Noreau, Luc, and Patrick Fougeyrollas. 1999. CMH MAAMARI, SOPHIA, and GUILLAUME Mesure Des Habitudes de Vie MHAVIE: Appendices PÉGON. n.d. “Les Relations Guide de L’utilisateur. D’interdépendance Par Lesquelles on Est Soigné: L’exemple Du Dispositif de Santé O’toole, Brian. 1988. “A Community-Based Mentale Soutenu Par Handicap International Rehabilitation Programme for Preschool Appendices

Disabled Children in Guyana.” International Ran, Mao-Sheng, Meng-Ze Xiang, Journal of Rehabilitation Research. Cecilia Lai-Wan Chan, Julian Leff, Peggy Simpson, Ming-Sheng Huang, You-He Parekh, Amrita. 2015. “Reaching the Shan, and Si-Gan Li. 2003. “Effectiveness Unreachable: The Promise of Telepsychiatry of Psychoeducational Intervention for in India.” Columbia Social Work Review 6 Rural Chinese Families Experiencing (1): 1–7. Schizophrenia.” Social Psychiatry and Patel, Vikram. 1995. “Explanatory Models of Psychiatric Epidemiology 38 (2): 69–75. Mental Illness in Sub-Saharan Africa.” Social Science & Medicine 40 (9): 1291–1298. Rathod, Shanaya, Narsimha Pinninti, Muhammed Irfan, Paul Gorczynski, Pranay ———. 2014. “Rethinking Mental Health Rathod, Lina Gega, and Farooq Naeem. Care: Bridging the Credibility Gap.” 2017. “Mental Health Service Provision in Intervention 12: 15–20. Low-and Middle-Income Countries.” Health Patel, Vikram, Ricardo Araya, Sudipto Services Insights 10: 1178632917694350. Chatterjee, Dan Chisholm, Alex Cohen, Mary Rebello, Tahilia J., Andrea Marques, Oye De Silva, Clemens Hosman, Hugh McGuire, Gureje, and Kathleen M. Pike. 2014a. Graciela Rojas, and Mark van Ommeren. 2007. “Innovative Strategies for Closing the Mental “Treatment and Prevention of Mental Disorders Health Treatment Gap Globally.” Current in Low-Income and Middle-Income Countries.” Opinion in Psychiatry 27 (4): 308–314. The Lancet 370 (9591): 991–1005. ———. 2014b. “Innovative Strategies for Patel, Vikram, Helen A. Weiss, Neerja Closing the Mental Health Treatment Gap Chowdhary, Smita Naik, Sulochana Globally.” Current Opinion in Psychiatry Pednekar, Sudipto Chatterjee, Mary J. De 27 (4): 308. https://doi.org/10.1097/ Silva, Bhargav Bhat, Ricardo Araya, and YCO.0000000000000068. Michael King. 2010. “Effectiveness of an Intervention Led by Lay Health Counsellors Richters, Annemiek, Cora Dekker, for Depressive and Anxiety Disorders in and Willem F. Scholte. 2008. Primary Care in Goa, India (MANAS): A “Community Based Sociotherapy Cluster Randomised Controlled Trial.” The in Byumba, Rwanda.” Intervention Lancet 376 (9758): 2086–2095. 6 (2): 100. https://doi.org/10.1097/ WTF.0b013e328307ed33. Petersen, Inge. 2000. “Comprehensive Integrated Primary Mental Health Care for Ridner, Sheila H. 2004. “Psychological South Africa. Pipedream or Possibility?” Distress: Concept Analysis.” Journal of Social Science & Medicine 51 (3): 321–334. Advanced Nursing 45 (5): 536–545. Petersen, Inge, Joshua Ssebunnya, Arvin Rugema, Lawrence, Gunilla Krantz, Ingrid Bhana, and Kim Baillie. 2011. “Lessons from Mogren, Joseph Ntaganira, and Margareta Case Studies of Integrating Mental Health Persson. 2015. “‘A Constant Struggle to into Primary Health Care in South Africa Receive Mental Health Care’: Health Care and Uganda.” International Journal of Mental Professionals’ Acquired Experience of Health Systems 5 (1): 8. Barriers to Mental Health Care Services in Rwanda.” BMC Psychiatry 15 (1): 314. Qureshi, NASEEM AKHTAR, HT Der Molen Van, Henk G. Schmidt, Tariq A. Al-Habeeb, Saraceno, Benedetto, Mark van Ommeren, and M. E. Magzoub. 2006. “Effectiveness Rajaie Batniji, Alex Cohen, Oye Gureje, John 48 of a Training Programme for Primary Care Mahoney, Devi Sridhar, and Chris Underhill. Physicians Directed at the Enhancement 2007. “Barriers to Improvement of Mental of Their Psychiatric Knowledge in Saudi Health Services in Low-Income and Middle- Arabia.” Education for Health (Abingdon, Income Countries.” The Lancet 370 (9593): England) 19 (1): 52–60. 1164–1174. Saxena, Shekhar, Antonio Lora, Jodi Morris, Birth Outcomes and Maternal Depression Annamaria Berrino, Patricia Esparza, in Jharkhand and Orissa, India: A Cluster- Thomas Barrett, Mark van Ommeren, and Randomised Controlled Trial.” The Lancet Benedetto Saraceno. 2011. “Focus on Global 375 (9721): 1182–1192. Mental Health: Mental Health Services in 42 Unzicker, Rae. 1989. “On My Own: A Low-and Middle-Income Countries: A WHO- Personal Journey through Madness and AIMS Cross-National Analysis.” Psychiatric Re-Emergence.” Psychosocial Rehabilitation Services 62 (2): 123–125. Journal 13 (1): 71. Scholte, Willem F., Femke Verduin, Astrid M. Veit, C. T., and J. E. Ware. 1983. “The Kamperman, Theoneste Rutayisire, Aeilko H. Structure of Psychological Distress and Zwinderman, and Karien Stronks. 2011. “The Well-Being in General Populations.” Journal Effect on Mental Health of a Large Scale of Consulting and Clinical Psychology 51 (5): Psychosocial Intervention for Survivors of 730–42. Mass Violence: A Quasi-Experimental Study in Rwanda.” PLoS One 6 (8): e21819. Ventevogel, Peter. 2014. “Integration of Mental Health into Primary Healthcare Slade, Mike, Victoria Bird, Clair Le Boutillier, in Low-Income Countries: Avoiding Julie Williams, Paul McCrone, and Mary Medicalization.” International Review of Leamy. 2011. “REFOCUS Trial: Protocol Psychiatry 26 (6): 669–679. for a Cluster Randomised Controlled Trial of a pro-Recovery Intervention within Ventevogel, Peter, Mark Jordans, Ria Reis, Community Based Mental Health Teams.” and Joop de Jong. 2013. “Madness or BMC Psychiatry 11 (November): 185. https:// Sadness? Local Concepts of Mental Illness in doi.org/10.1186/1471-244X-11-185. Four Conflict-Affected African Communities.” Conflict and Health 7 (1): 3. Thara, R., S. John, and S. Chatterjee. 2014. “Community Mental Health Teams WHO. 2001. “The Effectiveness of Mental in Low- and Middle-Income Countries.” Health Services in Primary Care: The View Epidemiology and Psychiatric Sciences from the Developing World.” 23 (2): 119–22. https://doi.org/10.1017/ ———. 2010. WHO-AIMS: Mental S2045796014000079. Health Systems in Selected Low-and Thara, Rangaswamy, Sujit John, and Middle-Income Countries: A WHO-AIMS Kotteswara Rao. 2017. “Telemental Health Cross-National Analysis. World Health in India.” Telemental Health in Resource- Organization. Limited Global Settings, 89. ———. 2011a. “Réadaptation À Base Thornicroft, G., and M. Tansella. 2004. Communautaire: Guide de RBC.” “Components of a Modern Mental Health ———. 2011b. “Réadaptation À Base Service: A Pragmatic Balance of Community Communautaire, Guide Du RBC, Livret and Hospital Care - Overview of Systematic Supplémentaire.” Evidence.” British Journal of Psychiatry 185 (October): 283–+. ———. 2012. “Les Premiers Secours Psychologiques: Guides Pour Les Acteurs Thornicroft, Graham, Til Wykes, Frank de Terrain.” In Les Premiers Secours Holloway, Sonia Johnson, and George Psychologiques: Guides Pour Les Acteurs Szmuckler. 1998. “From Efficacy to de Terrain. Effectiveness in Community Mental Health Services: PRiSM Psychosis Study 10.” The ———. 2015. “Guide D’intervention British Journal of Psychiatry 173 (5): 423– Humanitaire mhGAP (GIH-mhGAP): Prise 427. En Charge Clinique Des Troubles Mentaux, Neurologiques et Liés À L’utilisation de Tripathy, Prasanta, Nirmala Nair, Sarah Substances Psychoactives Dans Les CMH Barnett, Rajendra Mahapatra, Josephine Situations D’urgence Humanitaire.” Appendices Borghi, Shibanand Rath, Suchitra Rath, Rajkumar Gope, Dipnath Mahto, and Rajesh Wiley-Exley, Elizabeth. 2007. “Evaluations of Sinha. 2010. “Effect of a Participatory Community Mental Health Care in Low-and Intervention with Women’s Groups on Middle-Income Countries: A 10-Year Review Appendices

of the Literature.” Social Science & Medicine 64 (6): 1231–1241. Williams, J., M. Leamy, V. Bird, C. Harding, J. Larsen, C. Le Boutillier, L. Oades, and M. Slade. 2012. “Measures of the Recovery Orientation of Mental Health Services: Systematic Review.” Social Psychiatry and Psychiatric Epidemiology 47 (11): 1827–35. https://doi.org/10.1007/s00127-012- 0484-y. Winance, Myriam. 2008. “La Notion de Handicap et Ses Transformations À Travers Les Classifications Internationales Du Handicap de l’OMS, 1980 et 2001.” Dynamis 28: 377–406. Wright, Jerome, Stephanie Common, Felix Kauye, and Chikayiko Chiwandira. 2014. “Integrating Community Mental Health within Primary Care in Southern Malawi: A Pilot Educational Intervention to Enhance the Role of Health Surveillance Assistants.” International Journal of Social Psychiatry 60 (2): 155–161. Xiang, Mengze, Maosheng Ran, and Sigan Li. 1994. “A Controlled Evaluation of Psychoeducational Family Intervention in a Rural Chinese Community.” The British Journal of Psychiatry 165 (4): 544–548. Zimmermann, Maximilien. 2016. “When Psychological First Aid Is Not Enough: Personal Reflections on Psychosocial Interventions in Duma, a Village in North West Bank.” Intervention 14 (3): 200. https:// doi.org/10.1097/WTF.0000000000000135.

50 CMH Appendices Appendices

52 CMH Appendices Appendices

54 CMH Appendices Community mental health: Theory, practices and perspectives

This document is a compilation of thinking resulting from the seminar held in Kigali (Rwanda) on December 7 - 9, 2017, which brought together 45 participants from 12 countries to discuss community mental health concepts and practices. This document aims to provide a basis for exploring these concepts as part of more in-depth work, including an update of the 2011 mental health framework document.

The first part of this document focuses on the theoretical aspects and provides an overview of the literature on community mental health. The second part explores the practices. It sets out the specificities of HI’s positioning on community mental health, its projects and their shared characteristics, as well as the types of mental health and psychosocial support interventions deployed. This exploration closes with theoretical input looking at two key concepts which resonate with our practices: recovery and resilience.

Finally, the last part reminds us of the day-to-day challenges we face in the field, and the issues and perspectives for improving our mental health and psychosocial support practices.

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