On-line version ISSN 2309-8708
Psychol. Soc. n.39 Durban Jan. 2010
Is the glass half full?
Tanya M Graham
Department of Psychology University of the Witwatersrand Johannesburg Email: Tanya.Graham@wits.ac.za
Petersen, I, Bhana, A, Flisher, A J, Swartz, L & Richter, L (eds) (2010) Promoting mental health in scarce-resource contexts: Emerging evidence and practice. Cape Town: HSRC Press. ISBN: 978-0-7969-2303-5 pbk. Pages x + 222.
Promoting mental health in scare-resource contexts provides a welcome and stellar contribution to the body of knowledge on mental health promotion that adds the voices of prominent South African academics, researchers and mental health professionals to this field. As its title aptly suggests, the book centres predominantly on the concept of mental health and is situated within a mental health promotion framework. The book aims to provide a theoretical basis for the application of a mental health promotion approach within contexts with limited human, material and environmental resources, poor health infrastructure and underdeveloped health policies. In particular, the book seeks to develop and apply the theoretical premises of mental health promotion to the conditions and imperatives of LMICs, and illustrate their merit through using exemplars from different mental health interventions in these contexts. The book examines mental health using a lifespan approach to understanding risk and protective factors for human development, and demonstrates how interventions can be designed and targeted to promote wellbeing at different life stages. This review discusses some of the core critical debates that surround the conceptual basis of the book. The review then examines the specific chapters of the book and evaluates its particular relevance for LMICs.
The book principally draws from the World Health Organisation's ideas about the definition of mental health, the desirability of achieving mental health, the constituent components and drivers of mental health, and the key elements of a mental health promotion approach to research and intervention. As such, it defines mental health as being nested within healthcare and locates mental health promotion in the health promotion movement more broadly. The conceptual roots of the book are thus firmly embedded in the discipline of public health. Whilst the book adopts a public health epistemology, it attempts to explore elements of other theoretical approaches and their synergy with a public health framework (such as more critical, socially oriented and development based theories). However, the public health approach remains the core organising framework for the collation and synthesis of theory and research and the scaffolding used to support book's central tenets.
The public health perspective draws together the realms of health and public policy to create broad societal improvements to the magnitude and effects of communicable and non-communicable diseases. This perspective stems from a bio-medical tradition, although more recent trends have seen the increasing inclusion of psychological and social phenomena within its rubric. Mental health promotion, as a distinct paradigmatic approach housed within health promotion has evolved over the last century but gained increased attention over the last few decades from scholars from a range of health professions. In this time, there have been increased efforts to remedy the reputation of mental heath as being a less important aspect of health in comparison to physical health, and to address what has been largely noted as the neglect of this area. This has stimulated the emergence of several publications that this book now joins, although few of these deal specifically with mental health in LMICs like this one.
The title of the book alludes to a central paradox in the field of mental health promotion regarding the deficit versus asset connotations of "illness prevention and "health promotion". The book grapples with the conceptual tensions between the two, but maintains a primary emphasis on a "promotion" orientation, though acknowledging the interdependence of these constructs. The mental health promotion approach that is advocated attempts to delicately veer away from the deficit-orientated connotations of mental illness prevention and the disease model from which it emerges. It argues definitively that mental health promotion is more than a euphemism for prevention work, but simultaneously incorporates primary prevention as one form of mental health promotion. It supports an asset-focussed perspective on prevention, which acknowledges that most people remain free of diagnosable symptoms despite the presence of many antecedent factors for mental illness. However, this is a tricky tightrope walk on which maintaining a sense of balance in favour of a strengths perspective is at times difficult to maintain at some points in the book. The book describes mental health as more than a state of being free from diagnosable mental disorders. Rather, mental health is viewed as a state that includes an individual's capacity to fulfil their capabilities, cope with life stresses, work productively and contribute to his/her community (p3). The book identifies mental health has having intellectual, emotional and social aspects, and mental health promotion is viewed as engaging in forms of research and practice that improve a sense of wellbeing and competency in these realms. This strengths-based approach emphasises the importance of recognising and reinforcing factors that are deemed to facilitate mental health. This is a particularly useful approach in environments that present a myriad of potentially detrimental influences to human development. This positive approach is consistent with the more recent popularity of more positively orientated theories in health professions such as psychology.
The book does not fully engage with critical debates about the meaning of mental health and mental illness, and the forms of power and compartmentalised experience that are inherent in the use of these terms. Notwithstanding the contentiousness of definitions of "mental health" and "scarce-resources" and their western origins and assumptions, the book rather operates form the position of trying to adjust existing public health definitions to the contextual realities of LMICs. It thus attempts to foreground the social and community aspects of mental health and mental health promotion that are often overlooked. It draws attention to the very real connection between health problems including those related to mental health, and social or economic marginalisation and disadvantage. It draws attention to the ways in which factors such as poverty, malnutrition, rapid urbanisation, inadequate living and working environments, displacement and social exclusion in LMICS affect mental health, and successfully highlights the extent to which various forms of physical, material, social and economic hardship and oppression all have mental health correlates. However, most importantly, it also highlights how mental health may be maintained in the face of social and economic adversity. The book also acknowledges that mental health practitioners may have limited means of dealing with the challenges in LMICS, but nevertheless have a significant contribution to make in this area, and illustrates how mental health issues may be addressed despite the difficult realities that exist. The book shows how active efforts to advance mental health can be undertaken in a systematic manner, and based on a systematic analysis of the situation. Thus, the book supports evidence-based practice. It identifies multiple levels of protective and risk factors, which opens up multiple levels of potential intervention.
The book is divided into two main sections. The first section outlines the value and imperatives of a mental health promotion approach in scarce-resource contexts, and provides the conceptual tools for understanding the broad parameters of mental health promotion. This begins with situating mental health within the context of the global burden of disease and the shift towards a sustainable livelihoods framework for human development. This then continues with creating a conceptual overview of the importance of identifying theories of mental health promotion and mapping factors of risk and resilience comprehensively within an ecological model that addresses individual, interpersonal, community and structural levels. It is argued that this then provides the basis for which to design projects and interventions at these different levels.
Once the conceptual framework and overview of the book is detailed in Chapter 1, the book moves on to provide a very clear and incisive discussion of theories of mental health at the different ecological levels in Chapter 2. Individual level theories discussed include those related to health knowledge, beliefs, attitudes, motivations and behaviours. Interpersonal theories covered include those related to social cognitions, social support and theories related to parenting style. Community level theories include those related to social representations and identities, as well as social capital. Lastly, theories of public policy are discussed for the structural level. The chapter then counterpoises these theories at each ecological level with concomitant intervention approaches.
The book then progresses to presenting a novel and exciting perspective on contextual issues faced in implementing interventions in LMICS in Chapter 3. This chapter maintains a focus on factors encountered in the implementation process when engaging in the "real" world. Thus, it addresses what can occur in the gap between theoretical ideas and the translation of these ideas into everyday intervention practice. This includes relational, practical and material difficulties and dilemmas that may be encountered by mental health practitioners in low-resource contexts, such as issues of resistance to change and possible unintended or counterproductive effects of interventions. The chapter advocates a reflective practice that is mindful of differing cultural understandings and interpretations of the problem at hand. It argues that this will assist in framing more contextually sensitive intervention approaches and ultimately lead to valuable lessons and successful project outcomes.
Chapter 4 focuses on programme evaluation and advocates for the vital role that evaluation plays in programme design. The chapter distinguishes between the different characteristics of programme monitoring and evaluation. It identifies the key general theoretical parameters of programme evaluation. It provides a very thorough overview of formative, process and summative evaluation approaches and highlights their specific utility in enhancing the mental health benefits, scientific rigour and sustainability of a mental health programme. The chapter also highlights the particular contextual challenges that may be encountered in resource-limited settings that may affect the evaluation of mental health programmes.
The last chapter in this section, Chapter 5, deals principally with the dissemination and diffusion of information about effective evidence-based interventions, as well as issues related to programme sustainability and replication under varying conditions. It provides the tools with which to ensure the appropriate selection of interventions for a given context, establish the necessary buy-in and collaborative partnerships for a programme to succeed, and identify the "goodness of fit" between an intervention's constituent components, the characteristics of potential participants, and the choice of service delivery methods for a given context. The chapter highlights considerations for the translation of interventions that are conceptually sound, and have been tested and refined, into forms that are sufficiently responsive to contextual diversity, local conditions, and human, material, environmental assets or resource constraints. This chapter concludes the first section of the book and the reader is left with a comprehensive grasp of the cornerstones of a public health approach to promoting mental health, having traversed through the stages of problem identification, identification of risk and protective factors, intervention design, development and testing, and intervention evaluation, replication and diffusion. In addition to these elements, one is left with a keen sense of considerations to be undertaken in attempting to follow this framework in the midst of social and economic challenges, and the process issues, worldview clashes and tensions that may emerge when it is applied within a scarce-resource context. In addition, helpful tables, diagrams and boxes are provided to illustrate and highlight important points that may be consulted for easier access.
The second section of the book proceeds with the application of the aforementioned conceptual framework outlined in section one using a life stage model. This includes the phases of early childhood, middle childhood, adolescence, adulthood and older adulthood. A chapter is dedicated to each of these stages. Each of these chapters is devoted to presenting the current research related to the mental health of each group, as well as potential mental health interventions. In each of these chapters, examples of existing interventions in LMICs are used to illustrate the practical application of the principles in this text. In addition, intervention guidelines are provided to assist in targeting interventions for the specific mental health needs of each age group. As such, the book synthesises useful and scarce information about mental health programmes from a range of different countries.
This book will appeal to a wide audience in public health and mental health, and is deliberately inter- and multidisciplinary in its focus. It will appeal to and hold particular relevance for mental health practitioners, researchers, policy-makers and academics in field such as psychiatry, social work, psychology, education and nursing. It is an essential reference text for mental health practitioners. It can also be used as a seminal text for postgraduate students of public health, community mental health and community psychology. The book fills the need for theoretical coherence and consolidation in contemporary mental health research and practice within contexts of adversity. In the final analysis of the information presented, what emerge are the seeds of further critical innovation in using this approach in scarce-resource contexts. Thus, the book will undoubtedly serve to encourage and stimulate the growth and further development of mental health promotion field within LMICs.