Mental Health Promotion For People With Mental Illness

Part Two: Strategies

Boundaries

There are many different strategies that address mental illness and mental health problems. Although they can all be very effective for particular people or particular situations, not all fit neatly into a mental health promotion framework. Depending on the perspective one takes for understanding or explaining mental illness, there are different approaches one can take to address the situation. Of these perspectives and approaches, it is primarily the psychosocial, across the shaded lower half of the matrix below, which would most easily apply to mental health promotion. Explanations and approaches based on the biological perspective are less amenable to a mental health promotion model, although even these can be approached with an emphasis on consumer choice and control and an orientation toward recovery.

The following matrix offers a rough differentiation of concepts and strategies that would and would not fit with mental health promotion, but we must be content to view it as rough. The most important point, though, is that it is not only the type of mental health service which would define it as mental health promoting, but also the way in which it is delivered. All the services listed below would be compatible with mental health promotion only if delivered in a manner that emphasized consumer choice, control, dignity and recovery.

	Etiology	Service Approaches	Non-Service Approaches
Biological Perspective	Biochemistry Prenatal influences Brain development Genetic endowment	Medication ECT Nutrition Genetic testing and counselling Research
Psychosocial Perspective	Income (poverty), social support, education, physical environment (housing), work Cognitive world view Inclusion/exclusion	Psychosocial rehabilitation Cognitive behaviour therapy Skills building Participation in service design, delivery, evaluation Cross-sectoral linkages	Enhancing determinants of health and access to elements of citizenship Promoting consumer initiatives, self-help, advocacy Enhancing access to generic groups and organizations

Creating Supportive Environments

This strategy focuses on promoting community and organizational change to create healthy environments and access to social support (Willinsky and Pape, 1997, 2001).

Stigma

Community change is paramount to promoting the mental health of people with mental illness. This is largely because, of all the challenges in meeting the preferences of individuals diagnosed with mental illness, public attitudes regarding mental illness is one of the most confounding. Stigma impacts people's access to employment, housing, education, and inclusion in community life, and thereby impedes their chances for recovery.

Stigma can also interfere with access to services. In the United States, the Surgeon General report on Mental Health (1999) cites studies showing that nearly two thirds of all people with diagnosable mental disorders do not seek treatment (Regier et al., 1993; Kessler et al., 1996). While the reasons for this are varied, we know that stigma surrounding the receipt of mental health services is a significant barrier that discourages people from seeking treatment, and that stigma may be intensifying instead of abating over time (Sussman et al., Cooper-Patrick et al., 1997).

There is no simple or single strategy to eliminate the stigma associated with mental illness, but some positive steps have been taken. Research is showing that negative perceptions about severe mental illness can be lowered by furnishing empirically based information on the association between violence and severe mental illness (Penn & Martin, 1998). Advocacy and public education programs similarly help to shift attitudes, thereby contributing to the reduction of stigma (Surgeon General report on Mental Health, 1999).

One interesting finding which emerges with some consistency in the literature is that proximity or contact with people with mental illness disorders tends to reduce negative stereotypes (Corrigan & Penn, 1999). Thus programs that help people to become better integrated in the community through school, work, integrated housing, or interest-based social groups not only serve to promote the individual's mental health by reducing exclusion, but also can play a part in gradually shifting commonly held negative attitudes.

Inclusion

People with serious mental illness typically exist on the margins of society, excluded from mainstream community life. John McKnight has written eloquently about how "people with labels" can build on their own capacities and connect to community through mediating structures such as service clubs or interest groups (Kretzmann and McKnight, 1993). By refocusing services and policy outward to tap natural social resources already existing in community such as mainstream employment and education (with accommodations where needed), mainstream clubs, organizations and religious institutions, and mainstream housing, an environment more supportive of the mental health of people with mental disorders will be created. CMHA's "Inclusion in Community" project, described further on in this paper, applies these theories to people with mental illnesses.

Strengthening Community Action/Advocating for Change

Mental health promotion works through concrete community action in setting priorities, making decisions, planning strategies and implementing them to achieve better mental health. At the heart of this process is the empowerment of communities, and their ownership and control of their own endeavours and destinies (Willinsky and Pape, 1997, 2001).

For consumers, this strategy is critical, and underlies all the others. It involves creating supportive structures for people to organize, identify their own needs and issues, and act on them. For a pure mutual support model, these may require minimal financial resources, and simply the support for working together in groups that can come from an umbrella organization such as a self-help clearinghouse. For more ambitious undertakings such as building advocacy networks or community economic development initiatives, financial resources and organizational training will also likely be required.

Self-Help/Mutual Support

We come back to self-help/mutual support in many places in this paper because it is such a powerful mental health promotion resource. Because it is based on relationships with like people, i.e. others who have also experienced mental illness, self-help has been characterized as an exclusionary rather than inclusive approach. However, many people find that self-help groups not only help them deal with their illness-related issues, but actually support their confidence to move to more mainstream associations in the community (Trainor et. al., 1996).

In the past few decades, self-help groups have been increasing dramatically in number and popularity for a wide variety of health and social issues across the population. It is natural, then, that people who have been through the mental health system would also make use of this resource. For this population, self-help groups offer profound benefits. They not only provide the opportunity to share emotional and tangible support, but they make use of people's own strengths and capacities as sources of help for others. Based on principles of shared experience, joint ownership and leadership, and free of monetary considerations, self-help/mutual support represents a fundamental tool to allow people to work together and take charge of their own lives. Self-help groups offer a forum where individuals acquire the knowledge and skills to "get help," "give help," and "learn to help themselves."

Evidence for the effectiveness of self-help is starting to mount. In regard to people with mental illness, preliminary research findings just released from the Community Mental Health Evaluation Initiative in Ontario found that "participation in peer support is beneficial to consumers and to family members of ill relatives. Peer support programs are also having a positive impact on communities and systems serving the seriously and persistently mentally ill. However, these programs currently receive less than 1% of the ( Ontario) provincial mental health budget." Some particular improvements noted include community functioning, quality of life, symptoms, use of substances, and numbers of crises and hospital days (Centre for Addiction and Mental Health et.al., 2002).

In recent years, the array of initiatives that consumers control by and for themselves has expanded beyond self-help/mutual support groups to include other activities. For example, there are consumer-run advocacy groups and networks, consumer-operated businesses, consumers training other consumers in skills development, and consumers developing a base of knowledge for themselves. Unlike the pure self-help/mutual support model, some of these initiatives require a base of financial resources in order to be viable, and some have structures that include staff as well as volunteer leadership. They are distinct from formal mental health services, however, in that all the activities are generated by and controlled by the consumers themselves, working together. Examples of self-help approaches follow in the next section.

Building Individual Skills

Some of the skills that can be helpful and relevant to this population relate to managing the illness, others to activities of daily living, and others to participating in decision-making or advocating for change. Some of these can be transmitted by professionals or peers, while others can be developed by the individuals themselves.

Managing the Illness

For managing the illness, Cognitive Behaviour Therapy (CBT), generally thought of as a strategy for dealing with depression, has also been used recently in helping people through experiences with early psychosis. Usually delivered by psychologists, CBT helps people re-frame negative experiences in more positive and hopeful terms. As such, it can be a useful strategy to facilitate the steps on the road to recovery from a serious mental illness such as psychosis.

Daily Living

For dealing with day-to-day activities such as recreation, work, or school, some people can benefit from learning skills for managing time, requesting accommodations, or socializing with peers. These kinds of skills are often taught by rehabilitation counsellors, but can equally be learned from family or peers.
Participation/Advocacy Most policy-oriented activities that promote mental health such as participating in decision-making and advocating for change also require a degree of skills and confidence. Participation manuals or guides for boards and committees, pre-and post meeting briefing sessions for consumer participants, buddy systems, attention to language, and support groups for consumers who are involved in policy development across various groups and organizations, are just a few of the many strategies that have been proven successful for enhancing the strength of the consumer voice. In particular, participation in decision-making will be most meaningful when coming from a base of organized consumer self-help or consumer-run initiatives, and thus support for such initiatives is an important first step.

Individual Techniques: What Consumers Tell Us

There are also some proven effective measures that individuals can take to gain control of their situation and manage their mental health (Galipeault, 1998). Keeping the essential context of a supportive environment in mind, recognized mental health promotion strategies on the individual level, identified by consumers, are listed below:

• Educating oneself about the illness. Identifying symptoms and reviewing choices for managing those symptoms and making decisions about how to manage those symptoms that works best.
• Making choices about medications: find out about the side-effects of each, as well as, the effects of withdrawing (stopping use of) certain medications. Recording symptoms in a notebook while taking medication and use this to support or oppose continued use of a particular drug. These records can be used to work with doctors regarding the best choices for you.
• Exploring non-medication and non-medical approaches to managing symptoms and maintaining mental health.
• Learning various coping strategies and activities such as meditation, relaxation techniques, prayer, or hobbies that can help to reduce stress; joining clubs and organizations.
• Seeking employment and self-employment support programs.
• Seeking mutual aid opportunities such as self-help groups, community kitchens and food banks.
• Learning to make the most of social assistance programs, low cost transportation.

Using the Literature

Another interesting resource for building individual skills is self-help literature. The use of self-help books fosters self-determination. It also fits well with the Community Resource Base Model since the selection of books and the pace and manner in which they are studied is controlled by the consumer him/herself, the person at the centre of the model. Self-help books can be empowering, greatly add to the number of choices and options open to the individual, and enable him or her to exercise more control over mental health as well as other related areas in life (Dewar, 2000).

The Need for a Supportive Context

We finish this sub-section with a note of caution. For many consumers, their life experience directly impedes the acquisition of the kinds of skills and confidence we have been discussing. Therefore, before we can even begin to think about individual skills building and consumers exercising their rights and responsibilities, we have to take a step back.

Poverty and alienation result in the marginalization of this population and impede their ability to take control of their own mental health. Consumers have listed high rates of unemployment, employer discrimination, and splintered family support as community barriers to staying mentally healthy (CMHA NS Division, 1995). All of these experiences can batter a person's self-esteem and contribute to feelings of hopelessness. As well, many of the past and current mental health care settings, policies and plans have built-in components that reinforce and promote dependency.

To build individual skills, then, it is necessary to start with strategies, both service and community-oriented, that promote self-reliance, empowerment and choice. Disseminating guidelines for recovery oriented services and policies, combating discrimination, and encouraging consumers to build on their own strengths and capacities by adopting techniques such as those listed above or by organizing for themselves all create an environment where building individual skills will be more feasible and effective.

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