Sunday, March 08, 2009

Community-based Mental Health Programs: Back to Basics

In the report ”Integrating mental health into primary care : a global perspective,” the World Health Organization and the World Organization of Family Doctors bat for the integration of mental health care program with primary health care since it results in greater access to much needed services.

The report resonates with truth, considering that confinement in mental asylums or rehabilitation centers is a common treatment modality for mental disorders. For poor countries dealing with fund scarcity and the lack of specialists, a psychiatric hospital-based approach alone may not work. However, there are cost-effective models of community- and home-based programs that work well.

Community-based mental health program
A community-based mental health program is not meant to replace the treatment and services offered in hospitals; it rather complements these services by making these more accessible to the people.

Such a program is also more culturally appropriate and capitalizes on the tightly-woven social fabrics of most Asia-Pacifi c countries. The involvement of the
community and family members in caring for a patient helps ease stigma and provide a more healing and nurturing environment for a patient.

The shift to a community-based program is evident in Samoa, which deliberately closed down the mental ward at Tapua Tamasese Meaole Hospital. Mentally impaired in-patients are admitted at the general ward,usually for two weeks and are then sent back home to be taken care of by their families. Mental facilities are available at the primary health care level and mental health teams periodically visit the country’s two main islands to conduct assessments and followups.

Samoa’s approach to mental health adheres closely to its aiga culture - a culture that places utmost importance on the family and the value of kinship. David Lui, a Samoan mental health care provider, explains that “in Samoa, the unit of society is the family not the individual.” The Samoans’ preference to be taken cared of by their own families - and to personally take care of a sick relative - stems from this belief.

Starting a community-based program
In starting a community-based mental health program, it is important to provide community health workers with basic skills on mental health, such as the signs and
symptoms of different mental disorders to allow them to easily diagnose a patient.
In the manual “Where there is no psychiatrist,” Dr. Vikram Patel provided a comprehensive guide in implementing a community-based mental health program. As a general rule, health workers must establish rapport by treating the patient with compassion and respect.

Linkages with specialists should also be done to ensure that patients needing advanced medical care will be able to access this.

Interview is the fi rst crucial step in diagnosing a patient; a health worker must not rely on a patient’s outward appearance alone. Dr. Patel cautions health workers
against rushing through an interview since they might miss the real problem. In addition, it sends a signal to the patient that the health worker is not really

A diagnosis may be made based on the clinical manifestations of an illness, as well as a deeper probing of the patient’s personal life to establish why he or she is ill. For example, a patient may be depressed as a result of a particularly traumatic experience such as the death of a loved one.

Interviewers should also pay particular attention to a patient’s body language and expressions, such as restlessness, very fast or very slow rate of talking, and strange body movements.

Treatment and therapy
Depending on the severity of the illness, a health worker may opt to treat the patient or refer him or her to a specialist for advanced treatment. Medicines may be
prescribed to a patient, but health workers must ensure that proper doses are given and that patients are monitored for compliance as well as for side effects.

Counseling, when properly done, can also help a patient deal with his or her own problem. For some patients, the mere thought of having someone they can talk to and who is willing to listen to them is already therapeutic.

Aside from the usual treatment modalities, health workers can also tap into the local culture to devise innovative treatments. In Hawaii, for instance, researchers from the University of Hawaii showed that a residential program for substance-addicted pregnant and post-partum women was effective in rehabilitating the women. The program, called Na Wahine Makalapua (NWM), represented a paradigm shift from the way the island treats addicted Asia-Pacifi c islander women.

Instead of bringing them to rehabilitation centers and in effect isolating them, they were allowed to stay at home with their children as they recovered from their addiction. The setting provides the women with a nurturing and non-punitive environment where they are allowed to bond with their children and to resolve their issues without being judged. NWM also utilizes Hawaiian deep cultural therapy, which includes conflict resolution, storytelling, and massage. Like the Samoans, family is also integral for Hawaiians, and as such, mending broken family relations is essential for the women’s healing. Facilitating these processes are respected community elders.

In the Philippines, a local organization employs the play-and-learn method to teach children with mental and physical disabilities. Parents are also taught touch and massage therapy so they can do this at home.

There are indeed plenty of practices that can be adapted in any local settings and can be used to complement the traditional modalities.

Support groups
Setting up a support group can help both the patient and the family. A support group provides a patient with a sense that there are others who have the same illness. Patients can draw strength from each other as they struggle to cope with their illness.

For families of patients, support groups also give them a venue where they can share experiences and practical tips.

Caring for the caregivers
In most cases, a support group is perhaps the only avenue where the mental health needs of family members are met. This is a gap that needs to be addressed since family members, particularly the caregiver, are also suffering emotionally, physically, and mentally. A caregiver may suffer from a myriad of emotions ranging from anger, guilt, despair, and frustration. In cases involving a patient who has been incapacitated by an illness, a caregiver may have to give up his or her work and even social life to care for the patient full time.

Community health workers should take time to also talk with them and fi nd out how they are coping. Counseling - and even medicine - should be given when the caregiver is already nearing his or her breaking point.

This article is part of Issue 14 (2009) of Health Alert Asia Pacific published by HAIN

Lui, David. “Family – A Samoan Perspective.” Keynote presentation to the SF National Conference, Christchurch Convention Centre 13-14th September 2003. http://www.

WHO. “Situational analysis of mental health needs and resources in Pacifi c Island countries.” c_islands_needs_

Paula T. Morelli, Paula T., Fong, Rowena, Oliveria, Julie. “Culturally competent substance abuse treatment for Asian/Pacific Islander women.” Journal of Human Behavior in the Social Environment vol.3, issue 3/4 (2001): 263-280