In Seán O’Casey’s play ‘Juno and the Paycock,’ Capt. Jack Boyle drunkenly slurs a classic line that seems eternally relevant; “the whole world is in a terrible state o’ chassis.” Chaos, or the confusion that could lead us towards it, can seem ever-present in the distracting haze of modern life. We perform the balancing act of negotiating a path through this haze against a backdrop that sees us increasingly disconnected from nature and adrift from organised religion’s simpler answers. The radio tells us of Syrain refugees attempting to cross Balkan borders. Social media drip feeds bewildering updates of a millionaire celebrity’s bid for the Whitehouse. TV and newspaper journalists speculate as to the merits of the Irish government refusing a €13 bn. Apple windfall. With media-babble as a backdrop and modern life ever gathering pace through lightning speed technologies etc., it is no wonder that anxiety and stress related disorders are on the increase globally.
Fight or Flight
Stress triggers ancient protective mechanisms that, for example, prepare us for ‘fight or flight’. This response was very useful when ancestors were fleeing bears, but less useful when modern-day stresses leave us perpetually on edge, consciously or unconsciously perceiving threats that are not easily recognised or dismissed. Our evolutionary reaction to threat can lead to over vigilance, creating a variety of problems ranging from worry and tension to paranoia or psychosis. Fight or flight isn’t the only reaction our ancient programming has available however. Sometimes, our defence mechanism to modern life’s constant state of urgency is to retreat, become paralysed, avoid and withdraw. When this happens habitually, it can pave the way towards depression.
Depression, which is notoriously under-reported due to fear of stigma, affects by some estimates, up to 400 million people across the world. It is now recognised as the single largest contributor to collective years lived with disability worldwide. A World health Organisation (WHO) commissioned report from as far back as 2003 puts disability from mental disorders at twice the levels of cancer worldwide. Though this figure is by now quite dated, it is nonetheless shocking to realise that one of our most prevalent problems is probably the one least attended to.
A possible reason for this lack of attention comes from the front lines of the world’s most challenging situations. A March 2016 Guardian article quotes an International Medial Corps advisor:
“mental health is overlooked in both humanitarian crises and global development, despite its huge human, financial and social costs […] its one of those invisible crises, since people are not measuring it or looking at it” (Dr. Inka Weissbecker)
You cannot measure or describe something if you don’t look at it. In this way, mental health problems become like the proverbial elephant in the room, that is too large to miss, but somehow, since everyone conspires to pretend it isn’t there, it is therefore deigned taboo or untouchable. ‘Invisible’ and ‘overlooked’, locally and globally, sufferers of mental ill-health shoulder a dual burden; the debilitating effects of their illness and the stigma and marginalisation imposed by society through a combination of fear and prejudice.
Mental ill-health is one of the many ‘Others’ we bracket off from our lives, for the sake of a tidier, simpler existence. We collectively subscribe to a semblance of ‘normality’ that allows us to believe our brothers and sisters lost on the margins are beyond our ken. We are the ‘us’. Those unfortunates are the ‘them’. They can have our stares and maybe our sympathies from a safe distance. It’s a self-protection device to a perceived threat, but it stifles our empathy and makes their difficulties seem intractable. Subscription to ‘normality’ also allows us to sweep our own unwanted emotions and thinking patterns into the shadows where they can lurk as ‘bogey-men’ under our metaphorical beds.
Sustainable Development Goals
In 2000 the largest ever gathering of world leaders in history discussed what they understood then as the world’s most pressing problems. With elephants as big as poverty, hunger, gender equality and infectious diseases in their crowded ‘room’, it is perhaps no surprise that mental health evaded notice. Set with a deadline of 2015, the ambitious series of targets they adopted became known as the Millennium Development Goals (MDGs) and they have shown that apparently ‘monstrous’ problems can be tackled with a respectable measure of success. Though the MDGs unfortunately did not include mental ill health in their targets, last year saw the adoption of the Sustainable Development Goals (SDGs) and mental health has finally been acknowledged as the formidable global challenge it is.
Anxiety, depression, schizophrenia, bipolar disorder, substance abuse, and conditions like alzheimers, autism, epilepsy or mental retardation, that are, for policy purposes, labelled as ‘mental illness’ are among the ‘non-communicable’ diseases that world leaders have committed to reducing by one-third in the next fifteen years. ‘Goal three’ of the SDGs also undertakes to promote mental health and wellbeing, work to prevent substance misuse and achieve universal access to quality essential healthcare.
‘Ladder’ training provided by Donegal County Council sought to educate civil society regarding global development issues, and anyone who attended the training in Gaoth Dobhair will attest to a lively debate on these development goals’ usefulness, potential hidden agendas and relevance to lived experience in rural, Gaeltacht Donegal. Despite our reservations, the information shared was compelling and provocative and looking at examples like Ireland’ ‘Fair Trade’ towns , the conclusion I reached was that the adoption and adaption of these global goals at local level, is where a little magic could happen.
Another important insight from the process is that sometimes, developed and developing nations have very similar problems and the solutions to these and the resultant learning can be more transferrable than might be initially imagined. Rainwater harvesting methods used in rural Africa could inform water conservation and quality issues in Ireland for example. Though Irish people live in relative comfort to counterparts in developing nations, rural Gaeltacht Donegal is the most disadvantaged area of Ireland and although disadvantage can allow social problems to fester, it can also sometimes fire community spirit and necessitate initiative. Solutions that might come out of this context might have relevance beyond the local.
These solutions don’t always have to be ‘high level’ to have merit or relevance; often local, rural, even informal measures can represent the best use of otherwise invisible or unaccounted-for resources. Although the aforementioned global targets can try to drive change from the ‘top down’, sometimes, the most transformative work needs to be done at ground level.
In Donegal and some neighbouring counties the HSE and Community level organisations are collaborating to instigate ‘Social Prescribers’ to work in the gap between Primary Care and community level supports. The initiative has great potential to help smooth the delivery of mental health care supports in community rather than hospital settings. The idea is that new mums with depression symptoms could for example be referred to parent and toddler groups instead of being prescribed anti-depressants. An isolated rural middle aged farmer who only speaks Irish might find transformative social contact through a local community garden project where Irish is spoken. Informal supports that offer peer contact and use minority languages are the kind of nuanced ‘care’ that expert-led models cannot ever hope to provide.
I myself am involved in a community-level project called Lámha that hopes to research the potential mental-health benefits of these ‘soft’ community supports that social prescribing hopes to engage with. By contextualising this research alongside work in developing countries, we hope to mine the local, rural, informal measures for what learning resources they might have in a global development context. We don’t imagine the flow of learning will be one way. We expect there to be a productive exchange between ‘first’ and ‘third’ world responses. For example, free stress control classes provided by local organisation ‘Donegal Mind Wellness’, bear comparison to the work of Vikram Patel’s important mental health interventions in extremely low-resource settings in India where trained community workers delivered essential preventative mental health coping skills to larger populations than experts could ever hope to.
Recognising the primary importance of local solutions, the toddler or gardening group, Lámha ultimately wish to engage directly with local initiatives to train facilitators regarding the huge potential their often casual organisations have, to deliver meaningful ground-level mental health supports. We believe this local, intimate knowledge should not be underestimated in rising to the considerable global challenge that is mental ill-health.
Mental Health Care in the Community
When it comes to parity between physical and mental health as reflected by budgets or expenditure, our ‘first world’ economies are far from blazing a trail. Recent research from a European think-tank ‘Joint Action Mental Health Wellbeing’ quotes the EU average proportion of total health spends dedicated to mental health as a paltry 5.5%. Ireland comes in just below the average. The WHO estimates that this figure is below 1% in low-income countries. With the intention of attempting to close this gap the WHO launched the mhGAP initiative in 2010 to help developing nations scale up their mental health provisions. If developing nations are looking to developed nations for guidance regarding mental health provision, however, there is much potential for misguidance.
Across Europe, government-level change on mental health has been significant since the 1970s, idealistically built in no small part, on the work of Franco Basaglia’s brave 1960’s reforms. When Basaglia looked to close Italian ‘lunatic asylums’ and move towards community rehabilitation options, he understood that although the institutional model offered food, shelter and safety, it suppressed a person’s access to autonomy, liberty and love.
When the administrators got their hands on these reforming ideas, the devolution of the physical ‘asylums’, (perhaps misunderstood as a potential budgetary saving), was quickly achieved. ‘Care in the Community’ unfortunately seems to have often translated to repeating the model of providing food, shelter and safety, just in smaller, more locally-based care units.
I speak from a place of knowledge when I say that in my experience (watching from the legal and care-policy side-lines while a family member has been suffering severely for over a decade), the essential spirit of community-based reforms has been sadly lost in the process of implementation and considerable amounts of drugs are being used to fill the obvious and dangerous gaps.
While initiatives such as Social Prescribing aim to remove drugs from the equation where social anxiety or depression might be presenting, at the other end of the spectrum, care models can very dependent on drugs. The side effects of these drug cocktails leave people very far from the autonomy, liberty and love of the original ‘Care in the Community’ ideals.
Access to autonomy and liberty can, to an extent, be legislated and planned for from governmental level. At ground level however, it needs to be recognised that sometimes the best solutions to nuanced and seemingly intractable problems are often found by following the lead of a loving, accepting and understanding heart. To this end, mental health service-users, their families and their supporting communities need to be meaningfully and consistently engaged.
Analysis of the situation in Ireland, Europe and the US (where ‘Care in the Community’ policy implementation is at a relatively advanced stage), all point to similar findings. The hidden, potentially powerful resources and learning provided by life experiences of service-users, their families, carers and wider communities are key components to sustainable and successful solutions. It is essential that this insight doesn’t become a ‘box-ticking’ exercise however, where ‘consumer’ input is gleaned in innovative recovery-based pilot programmes, but never rolled out across the board.
Much work also needs to be done to prepare the ground within the community, so that people presenting with problems, be they straight forward or complex, will not continue to be marginalised and misunderstood. Persistence of fear and stigma is at one pole cutting off people from potential community-level resources and in the worst case scenarios leading to needless loss of life or the sweeping of society’s most vulnerable towards homelessness and the snare of the criminal justice system.
Out of the Shadows
April 2016 saw the WHO and the World Bank co-hosting a high-level global meeting entitled “Out if the Shadows: Making Mental Health a Global Priority.” Discussed at the meeting was fresh WHO research that found global failure to tackle depression and anxiety (the world’s most common mental health problems), to be costing the world nearly $1 trillion a year. Without treatment, an astounding 12 billion working days, or 50 million years of work could be lost between now and 2030, with an annual loss to the global economy of $925,000,000,000,000. (In case, like me, your brain is boggling, let’s clarify here that a trillion has 12 zeros, a billion has 9.) They’ve calculated also that for every $1 invested in mental health, a $4 return is achieved. When high-level bureaucrats calculate figures of this magnitude, one can expect a raft of policies to follow. We better dust off our shadows!
Forgive my off-hand tone. Of course it is ultimately a good thing that a strong global light is being shone on mental health’s largely invisible crisis, but I struggle to get on board when pain is measured in numbers. I also tend towards distrusting the motives of ‘money men’. The world will take notice of these incredible figures however. And well it should, but, (perhaps you can sense a pattern forming), I also distrust the outcomes of ‘top-down’ initiatives. In fact, according to the aforementioned research from the European think-tank, in the area of mental health advocacy and public education, government-led programmes are the least successful, being considerably outperformed by charity (NGO) or family-led initiatives. Interestingly, as recent evaluation of Ireland’s 2006 reforming mental health policy document ‘A Vision for Change’ draws very similar conclusions.
Ground-Up vs. Top-Down
Decrees from ‘on high’ have a tendency to foster tunnel-vision rather than appreciating nuance and I believe nuance has a particular place of merit in the field. Families and community groups are uniquely placed to understand the subtle shadings of nuance, be it culturally or individually specific. By comparison, imposing solutions through policy innovation formulated higher up in hierarchical structures frequently grows a net of unintended negative consequences, the effects of which are typically only understood ‘on the ground’. When mental institutions, or acute hospital services are closed for example, without first putting the necessary primary-care and community level 24/7 crisis supports in place, the ground is quickly littered with anecdote after anecdote of sadness, trauma or missed opportunities for useful interventions. This would not happen if solid foundations were initially built into the support system, from the ground up.
I firmly believe that the greenest shoots of hope grow from the ground. Organic innovation is however frequently missed in research gathering, and its apparently ’common-place’ nature belies its transformational power. At this particular historical moment, when our ‘state of chassis’ is at last being recognised at a global level, developing countries will undoubtedly be looking to follow the developed world’s lead. At this crucial juncture, ‘bottom-up’ community-derived mental wellness solutions need to be acknowledged and evaluated as the potential gold-dust they are. Supports being provided by local community-led mental health initiatives is a vital ‘entry point’ towards lasting solutions in the field of mental health. If nurtured, they will grow and bear very good fruit.
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The contents of this article are the sole responsibility of the author, and can under no circumstances be regarded as reflecting the position of ALDA and the European Union.