file · web viewthe study makes controversial claims but ones that go to the heart of the debate...

SAPC Integrated Health Strategy

The Problem

According to a landmark study by the London School of Economics (LSE), eliminating

depression and anxiety would reduce misery by 20% compared to just 5% if policymakers

focused on eliminating poverty.1 This is important when considering that material needs

(health and income) can so often trump psychological needs in national and personal

budgets. Very often health systems, like the NHI, when short of money, cut mental

healthcare. Sue Bailey, the retiring president of the Royal College of Psychiatrists, called the

situation a "car crash", alluding to the fact that cuts in psychological therapy cause far more

problems than they solve. In the LSE study Layard argues that, “Tackling depression and

anxiety would be four times as effective as tackling poverty. It would also pay for itself.”

The study makes controversial claims but ones that go to the heart of the debate especially

in an emerging economy. This debate and these issues are critical for us as South African

mental health practitioners, they raise crucial questions. What is the relationship between

material and psychological needs? With such a long history of trauma and poverty in the

country how should a national health model best articulate mental health issues, economic

issues and human rights issues? How best to treat individuals in situations of collective

pathogens like trauma and bigotry? Is it sensible to treat an individual who returns to a

community where there is no safety and where there is every possibility of re-traumatizing?

How to provide safe havens for people outside of hospitalisation? How best to provide long

term treatment to people who need it but cannot afford it? How to provide affordable short

term interventions? What is the best way to balance these competing needs in the South

African situation? How do these considerations affect diagnosis? What forms of

interventions should be advocated? Should mental health focus on symptom relief or

structural/social change/revolution? What resources are to be used? How can available

resources be better used? How to manage dual diagnoses especially addiction?

Prevalence and under-representation of mental health difficulties

With a high prevalence rate in South Africa, mental disorders and their associated

1 http://www.independent.co.uk/news/science/happiness-study-lse-mental-health-relationships-money-does-not-dictate-subjective-wellbeing-a7468676.html

Peters May 2017 1 | P a g e

http://www.bbc.co.uk/news/health-27980677

psychosocial and physical disabilities contribute substantially to the burden of disease and

to health costs. Inadequate public health resources and a chronically overburdened health

system result in limited access to psychiatric care. Unmanaged, these conditions spill out

not only into secondary health and economic conditions for individuals, but also collectively,

overburdening domestic and communal structures and fomenting levels of frustration and

desperation conducive to other social ills. The relationship between mental health and

material considerations is important not only individually but also structurally. How to

provide affordable healthcare is a global debate with various models being explored. At the

heart of the matter is the question, given that disability impacts on a person’s material

situation how best can industry and government provide affordable healthcare to all of their

citizens, especially the most vulnerable? Even more crucial is the question of prevention.

Philosopher Richard Rorty argues that the consequences of economic prejudice is often overlooked

“Surveying academia, for example, he observes that “nobody is setting up a program

in unemployed studies, homeless studies, or trailer-park studies, because the

unemployed, the homeless, and residents of trailer parks are not the ‘other’ in the

relative sense. To be other in this sense you must bear an ineradicable stigma, one

which makes you a victim of socially accepted sadism rather than merely of economic

selfishness.”2

This suggests that the impact of social systems is more readily critiqued than the impact of

economic systems. In South Africa the stigmas and impacts of both of these structural

systems, the social and the economic coincide, individuals and collectives experience the

effects of both “the socially accepted sadism” and the “economic selfishness”. A person’s

physical, mental and social health is determined and limited in many structural ways whose

interrogation is also structurally determined, controlling what may be discussed and made

conscious. This censorship and repression may be referred to as the collective unconscious

of society, revealing and concealing the ways in which an individual’s mental health and

economic prospects interact and are structurally determined.

In a recent article Business Day3 editor proposes that the way forward for South African economy 2 https://www.theatlantic.com/politics/archive/2017/07/advice-for-the-left-on-achieving-a-more-perfect-union/531054/?utm_source=fbia3 https://www.businesslive.co.za/fm/features/cover-story/2017-05-11-peter-bruce-how-to-fix-sa/


“Fundamentally, there are three reforms to which business needs to accede to. First, it must work much closer with labour. Second, it needs to begin to think and behave long-term rather than chase quick results. Third, it needs to create an immense pool of capital from within its own resources with which to help repair the country. Government should talk to business and labour about adopting the German model of mitbestimmung or co-determination, in SA. If either resists, simply impose it… The second thing business has to do is to stop chasing quick executive enrichment. It widens inequality and threatens the long-term survival of our market economy… Finally, business should revisit an idea one of its own, Jacko Maree, had years ago. If every company on the JSE were to issue, over a period of two years, new shares equivalent to 1% of its market capitalisation they would raise, at the current JSE market cap, about R140bn. Company share prices can move either way by more than that on any one day and no-one turns a hair.

This would be pooled into a development trust, run purely by the private sector. Trustees would not be paid and their remit would be to spend it fast. Ask the state what it needs. Fix the hospitals? Sure, but what the trust spends its money on, it gets to manage. Deal?

People say that when Maree had that idea it might have been possible, but that because foreigners own so much of the market here now, it would not be doable. I disagree. Foreign investors know better than we do how important it is to have an SA at peace with itself.”

The principles outlined by Bruce regarding the economy are analogous to the health sector

which is also plagued by fragmentation, short-termism and lack of co-determined capital. In

terms of the gulf between private practitioners and those working in public- health there is

little opportunity for private practitioners to engage with the over-burdened and under-

functioning public health system, either because of a shortage of advertised posts or

unattractive working conditions. In certain respects this disparity mimics that between

business and labour. As a consequence this results in the superfluity of the well-educated

health providers, unwilling or unable to enter the (discredited?) government service.

Mike Berger voices the much-expressed opinion of many NHI insiders when he argues that

our Minister of Health has once again resurrected the idea of a National Health

Scheme. Although there is some confusion over the precise details of his proposal, it

needs to be pointed out that the provision of a broad-based health service, especially

within a country like South Africa, is one of the most complex, contentious and

difficult tasks imaginable. Until we show the capacity for such an undertaking it


would undoubtedly become a greater albatross around South Africa's neck than the

much-touted nuclear energy deal.

This is not an argument against a more just and effective health service for all

citizens. But to do that will require some serious soul-searching and thought to the

complexities and skills of all kinds required. In the meantime build up capacity,

improve service attitudes and introduce workable incremental reforms. These will all

be difficult enough.”4

The majority of registered practitioners are working in the private sector (REF) and although

many practitioners are involved with select NGO’s on a volunteer or reduced basis and

charitably offer their services on a sliding scale for those unable to afford the full rates, the

majority of practitkioners are denied not only the opportunity and experience of working in

the public health services but also of having an impact in a broader circumference.. For

logistical and theoretical reasons many practitioners are unable to be involved in setting up

and managing inter-disciplinary collaboration. This means that a person working in private

practice may predominantly work individually on a one to one basis and have little up to

date information and capacity to impact on the social and structural issues affecting their

clients. In the process of these patterns forming differentiation is also set in in other areas In

practice and in theory a dichotomy is set up, e between “hard and soft” skills, where hard

skills are more concrete and economic and soft are more social and psychological

understanding. It does not take much imagination to consider that this distinction echoes

other social categories like gender. where certain organisations do certain specific

interventions in one systemic area and others in another area. There is little opportunity to

articulate interventions between these levels to provide safety, support and possibility in

the external world while examining their effects on the internal world. We need to work at

the place where these and other worlds meet. That mental health and income generation

are mutually supportive and by articulating mental health initiatives with income-generating

initiatives, as some individual NGO’s have successfully developed to much acclaim, we might stand a

better chance of ensuring that the work of individual paradigms and practices get traction,

enhancing buy-in, compliance, sustainability and broadening the reach of this best-practice model.

4 http://www.politicsweb.co.za/opinion/avoiding-collapse


This would require the research and development of viable and sustainable models of

integrated interdisciplinary mental health care services and to carefully collate, differentiate

and articulate capacity until such a time that it is useful and possible to affiliate these tried

and tested methods into a public health system. Such ideas echo Bruce’s proposal of

encouraging mitbestimmung or co-determination in an integrated approach of diverse health-

care providers and users, with a concerted focus on long term goals and broad structural

change.

At the same time, still focussing on finances, such a proposed system, hamstrung by the

absence of financing that would ordinarily have been undertaken by government would

need to find alternative means of funding. Since it appears that this may not be undertaken

swiftly or effectively by government without the recommended daily allowance of corruption

which, rumour has it, has already infiltrated the NHI planning, it might be necessary to turn to the

private sector and international affiliates. Certainly medical aids like Discovery are already

investigating such an integrated health model in their push for preventative treatment knowing how

it affects the bottom line. Bruce’s last point, a form of capitalising and development which is

co-invested and co-determined by, for instance, pooling 1% of companies market capitalisation

or social development fund is a creative option and this, in addition to a number of international

funders could be held in “a development trust, run purely by the private sector. Trustees would

not be paid and their remit would be to spend it fast. Ask the state what it needs. Fix the

hospitals? Sure, but what the trust spends its money on, it gets to manage.”

What is the distinction between collaborative approaches and integrative approaches in

South Africa?

In South Africa there is a history of collaborative care approaches in mental healthcare

service provision e.g. (REF).In such approaches providers have independent services and

care plans and collaborate together, communicating and partnering on the comprehensive

treatment of a client. (REF), these may include working in parallel or the specific sequencing

of treatments (e.g. step care).

Integrated care, on the other hand, refers to models where a multidisciplinary team

integrates its approaches in an overall approach to the care of an individual. This approach


has been used more frequently with children and adolescents and in situations of dual

diagnoses (Gum, Arean & Bostrom, 2007; Harpole et al., 2005; Huang et al., 2009)5

Integrated care is an approach that is both broad-ranging and inclusive, examining

numerous health, social and economic health determinants, extending to a plurality of

clientele (partners, family members, peers and communities)6 and administered by a range

of service providers, specialists and support workers. (Canadian Psychiatric Association,

2000; Bazelon Center, 2010; Daniels et al., 2009; Collins et al., 2010; Hollander & Prince,

2008; Unutzer et al., 2007). 7

What is the unique goal of integrated mental health care and how is it distinct from other

approaches?

The South African bill of rights includes the Right to Health which it details as follows

(8) A comprehensive national health service shall be established linking health

workers, community organisations, state institutions, private medical schemes and

individual medical practitioners so as to provide hygiene education, preventative

medicine and health care delivery to all.

In line with the detailing of this right to Health the overall goal of such an intervention is the

provision of a variety of services to better meet the health service needs of the individual

while addressing rising costs of care. This work requires understanding the options for

integrating mental health treatment for individuals who have complex treatment needs and

for whom access to primary care through traditional models may be limited.

A truly client/patient-centred approach would consider the approach that best meets the

health needs and goals of a particular individual or population, providing the least intrusive

option appropriate to the particular needs. The flow and amount of service provided

changes as the individual’s needs change.

5 In http://www.health.gov.bc.ca/library/publications/year/2012/integrated-models-lit-review.pdf)6 For instance, AKESO’s byline is the promise that a “ multi-disciplinary team of psychiatrists, psychologists, occupational therapists, social workers, pharmacists and nurses all work together with you and your loved ones to ensure the best possible care, and best possible outcome.”7 ibid


http://www.health.gov.bc.ca/library/publications/year/2012/integrated-models-lit-review.pdf

Given the resource-heavy management of an integrative approach, it would be important to

differentiate these two approaches, collaborative and integrative, in terms of what is proven

to be the most appropriate and cost-effective approach. It would also be important to

ensure that the co-operation of the team of diverse roleplayers is secured within an

integrating framework which maximizes co-operation while preserving the uniqueness of

each responsibility, so that the treatment plan is not fragmented and competitive with

patients pulled in different directions.

Who is the SAPC?

The SAPC is a collection of over 50 groups of mental health service providers from a range of

disciplines sharing a common pursuit of the Psychoanalytic paradigm.

Why would the SAPC be well placed to explore an integrated health strategy?

Such a collection of disciplines and projects gathered together under a common paradigm

(rather than a common profession or target population) is relatively uncommon and, in its

rich diversity, is a micro-analogue of the national mental health services offering the unique

opportunity of piloting how to coordinate diverse psychoanalytic approaches and practices

into a collaborative or integrated biopsychosocial health strategy.

Why would such an approach be particularly suited to conditions in South Africa?

Many of the multiple variables that impact on the mental health of the majority of South

Africans are inherited; they have been received and passed down inter-generationally.

Historically, the trauma and violence of Apartheid disrupted domestic and community

structures, catapulting people into migrant labour, exile and resistance training. The

consequences of this interruption of ordinary psychosocial development continue to be felt

today in terms of domestic violence, substance abuse, gender violence and other variables.

Circumstances have changed far too slowly and within such a context one would be hard-

pressed to offer a single diagnosis to the exclusion of these other factors, frustrations and

challenges. Many community structures remain materially unchanged and psychologically

unhealed. For the majority of South Africans Individual prospects for self-improvement

seem not to have improved as much as hoped, meaning that the basic markers of health:

the capacity to work and love remain out of reach. This complex situation where the


collision of history and current situation, as well as the intimate reciprocity between

individual and social factors suggests that it is realistic and suitable to offer a multi-

pronged treatment for individuals who have multiple factors co-occuring. Perhaps in a first

act of healing the health-care providers need to model such integration by engaging in a co-

operative venture where, rather than duplicating services or competing in fragments,

different players with specified roles strive to work efficiently and creatively together.

Why now?

As ongoing NHI discussions proceed haltingly with the ever-changing situations and

representatives of governmental, industrial and registration bodies it would seem

opportune to research, develop and pilot our own integrated Psychoanalytic approach to

mental health. Without the overwhelming constraints and vagaries of a national roll-out we

have the advantage of discussing and documenting existing work locally, regionally and

nationally, as well as consolidating training initiatives as well as piloting and evaluating new

collaborative work on a smaller scale before being in a position to argue for the advantages

of an integrated Psychoanalytic approach either as an integral part of or as an adjunct to the

NHI.

Why an integrated Psychoanalytic mental health plan?

As argued above, an overarching paradigm would serve the integration of the treatment

plan. There are important and interesting reasons why I propose that the Psychoanalytic

paradigm is best suited for this umbrella or containing role.

The definition of human rights is effectively a definition of general health, especially mental

health8, of individual and country. Full health therefore does include the safety and

containment in which to exercise your humanness with dignity, as the bill of rights clarifies,

the right to life, dignity, home life, privacy, movement, conscience, religion, creative

freedom to the right to work and to love especially for minorities and vulnerable parties.

To achieve this definition of health in a sustainable way we need to look beyond mere

somatic symptoms and loss of productivity. We would need to work at the level of cause

rather than mere symptom or behaviour. This is where the legacy of psychoanalytic work is

8 Freud’s famous saying, “love and work are the cornerstones of our humanness”


able to extend beyond individual health concerns and become the work of communal

health: that is to say the promotion and protection of human rights.

Psychoanalytic work distinguishes itself from other psychological interventions in its deeper

engagement with the causes and patterns of difficulties. Rather than being content with

merely addressing conscious or apparent symptoms or thoughts or behaviours,

psychoanalytic work unearths the root of these difficulties in our adaption to difficult

personal histories. The metabolising of our national histories is not a foreign concern for

anyone living in South Africa currently where it is very clear that without a consideration of

deeper historical concerns the unworked through history rises up and topples plans our

well-made plans in sometimes life-threatening ways. This teaches us again that we cannot

be satisfied with short-term fixes. The ecosystem in which we find context, whether

individual or collective, insists on an inclusive wholeness and integrity where there is a place

for everyone; it pools up and explodes where there are unconscious exclusions,

polarisations and obstructions.

The Psychoanalytic treatment may possibly take longer but its deep, sustainable and broad

reaching effects in terms of treatment and prevention are beneficial not only for individuals

but also for collectives, increasing co-operation and social integrity9. While it may be

convenient or pragmatic to locate mental illness within the individual so that affordable

short term treatment can be applied to the individual there is great agreement that not only

is such an approach misguided in that individual mental illness is a result of an impacts on

the collective, but also that such an individual approach stigmatises (scapegoats) the

individual in a way that compromises the seeking of and cooperation with treatment. The

effects of psychoanalytic interventions, whether working at the level of individual, couple,

family, group or community individuals give rise to a deepening integrity which can then

allow a full and comfortable engagement with each other using all faculties (emotionally,

intellectually, socially, creatively and physically). With greater self-knowledge, emotional

and intellectual capacity and robustness is increased which enables greater engagement.

9 See the work of SINANI in KZN for example which works through groups of individuals, running ongoing personal, social and professional development groups for women, men and children as well as being requested to support at the level of community leadership.


It becomes apparent that in order to achieve mental health in a sustainable (and therefore

ultimately economic way) not only do all health workers need to link their efforts together

collectively, as suggested, in an integrated way but also that their combined focus should

itself be more take into account the reality of various structural contexts impacting on an

individual’s mental health, ie Psychoanalytic. This requires assessment and intervention at

various structural levels, examining deeper causal dynamics at individual and social levels.

Like this, by addressing symptoms and multi-level causes, not only is individual prognosis

improved (REF) but future difficulties may also be averted, that is to say it would have both

a treatment and a preventative aspect.

What sort of practitioners are needed to implement this plan?

Interventions which address both symptom and structure are health-promoting and cost-

saving, they require a range of competencies and approaches. Thankfully there are

practitioners who are skilled in all of these areas and many of them are working in such

overlapping territories. There are also a number of partnership organisations actively

working in Public Health10 who are affiliated with individuals and SAPC groups, many of

these organisations are members of SAPC

What is the unique contribution of SAPC to such an integrated health plan?

Our recent conference, Couch and Country demonstrated clearly the extent to which our

diverse SAPC membership, individuals, groups and organisations, is involved in various

traditional and non-traditional Psychoanalytic interventions in the country and that they are

thinking about their work and writing it up. This means that there is a massive pool of

resources, over 50 groups, over 500 providers as well as their pre-existing relationships with

various projects, organisations and institutions. Many of the interventions presented at the

conference are themselves examples of integrated approaches to mental health, for

example, one of our member groups Johannesburg-based Lefika is able to offer a wide-

range of creative options for individuals and groups ranging from art therapy, singing,

10 Wikipedia defines Public Health as "the science and art of preventing disease, prolonging life and promoting human health through organized efforts and informed choices of society, organizations, public and private, communities and individuals."[1] It is concerned with threats to health based on population health analysis.[2] The population in question can be as small as a handful of people, or as large as all the inhabitants of several continents (for instance, in the case of a pandemic). The dimensions of health can encompass "a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity," as defined by the United Nations' World Health Organization.[3] (https://en.wikipedia.org/wiki/Public_health)


https://en.wikipedia.org/wiki/Public_health#cite_note-3

https://en.wikipedia.org/wiki/World_Health_Organization

https://en.wikipedia.org/wiki/Pandemic



https://en.wikipedia.org/wiki/Health

boxing, craft, as well as both individual and groupwork. In this way an approach can be

chosen which suits even the most under-resourceding situation (think of the Ububele

Babymat example) practitioners can agree on what would be suitable and clients can choose

what they are drawn towards. Such a menu of modalities offers a greater possibility of a

strategy being found that is particularly suitable and accessible, developmentally and

constitutionally, for an individual or group. As discussed various modalities can be tailored

together into a programme of treatments juxtaposed in parallel or sequenced appropriately.

Similarly, on a broader scale, in the confederation with its 50 shades of Psychoanalytic

thinking, groups have a defined expertise in multiple mediums and modes of working

psychoanalytically specialising in certain conditions and with specific populations, with

individuals, couples, groups, communities and industry. Held together by the

psychoanalytic paradigm such diversity can be meaningfully articulated in a meaningful way

to produce and pilot its own collaborative and integrated health plans.

As a confederation of different groups, with different core professions we remain resolute in

representing, protecting and developing the cooperative potential in our diverse

membership. In terms of this we propose the following process for further discussion and

actioning:

(scroll down)

Draft SAPC Vision and Action Plan for 2017


1. Clustering: the galvanising of the different professions and areas of focus represented in our membership. That is to say all the professional categories represented in our membership: analysts, psychologists, social workers, art therapists, registered counsellors, nurses, community workers to form lobbying groups

1. This professional diversity is being accessed through David’s developing questionnaire which is almost ready.

2. The establishment of an


1. Clustering: the galvanising of the different professions and areas of focus represented in our membership. That is to say all the professional categories represented in our membership: analysts, psychologists, social workers, art therapists, registered counsellors, nurses, community workers to form lobbying groups 2. The establishment of an

Training and Resources: Integrated approach requires Task Shifting and delineation

Such development must incorporate the roles, responsibilities and scopes of practice of each

cadre of health worker involved in the delivery of lifecycle systemic healthcare. To co-ordinate

this more clearly would require a careful delineation of the nature of the intervention as well as

the skills of the role-player and the nature of their support/supervision.

Membership: In order to set some sort of measurable standard to our memberships

4. This can be achieved by posting a series of readings or lectures, in real time or virtual,


Secondary Post Graduate training a) draw up an inventory of all the training initiatives currently being undertaken by our membership: (e.g. SAPI, SAAJA, Masterson, Kohut, groupwork , couples, etc.)

(b) Explore the possibility of setting up a post-graduate psychoanalytic psychotherapy training (FR)

a) (b) Explore ways of ratifying training.

7. (a) Establish which individuals or groups offer specialist training (this is covered in the questionnaire) (b)Collate all the trainings on offer.c) Engage in designing and negotiating re PG Psychoanalytic Psychotherapy Training(c) Discuss with all training groups the ratification of training either through the qualification trio (SAQA, DHE, HPCSA)or lobby to be mandated to do the quality control as SAPC (ourselves) like the BPC has done.

Membership: In order to set some sort of measurable standard to our memberships

4. This can be achieved by posting a series of readings or lectures, in real time or virtual,

2017 Strategies:

1. SAPC dialogues: to discuss, research and learn what is being done and thought about

a. Gather team of planners


b. Set up roster including groups

c. Logistics

i. Event organiser/panel

ii. Publicist

iii. CPD officer: needs programme, CV’s etc.

iv. Audiovisual person

v. Payment of participants

2. Attendance of conferences: ibid

a. (http://www.saacapap.org.za/about-us/association-benefits.html)

b. Digital one in Jhb (5 July, Emphosa Maphosa Management, already put in

place one day summit: Mental Health Developments Summit to be held at

Emperors Palace Convention Centre, Johannesburg on the 5th July 2017.

3. Consultation with BPC, WPC, ASEKO, GAIMH, LEFIKA, Calabash etc.

4. Employ researcher to do meta research of literature on integrative mental health

practices

5. Collate the dialogues, conferences, discussions, literature programmes

a. Employ someone to renew SAPC handbook

b. David’s questionnaire will bring that up to date

6. Training

a. Agree on entrance requirements for membership

i. Already asked membership for recommendations of lit/clips

b. Set up training options for different strata of membership

c. Reopen the debate regarding register

i. Already asked membership to endorse whether they meet SAPC

criteria

d. Set up concentrated workshops on psychoanalysis for various professions

outside of SAPC.

7. The setting up of integrative cases with pockets of select practitioners nationwide

a. Standardise an evaluation process

b. Write up case studies.

8. Preparation for 2018 conference in Jhb

(Continue scrolling down for Phase 2)


http://www.saacapap.org.za/about-us/association-benefits.html

Phase 2: Treatment Pilot Programme

Vision

Health care built on community knowledge and participation, delivered by a collaborative

team of professionals supporting patients and caregivers to effectively manage their own

health condition. Core health services are provided in community settings and committed to

effective care for the entire population. Health care is measured by successful

client/patient and provider experiences that reduce the need for people to require urgent

care in emergency departments and hospitals.


Proposal

The proposal is that SAPC explore the development of an integrated approach with the

possibility that such a model is viable when all providers share a common psychoanalytic

paradigm to various degrees from lay counsellors to analysts.

1) Accessing of practitioners

a) Set up a roster of individuals who (i) are already involved, (ii) express an interest to

be more involved in public health work (aka outreach work)

b) Explore the possibility of setting up little teams of multipractitioners who can begin

to experiment working together in an integrated way, documenting the strengths,

weaknesses, opportunities and threats of such an endeavour.

c) Access literature and supervision to guide this work (contract the researcher to trawl

the literature for this.)

2) Accessing of patients

a) Send out word to membership and partnership. Have meetings with partnership to

explore options. What options for cooperation are there?

3) Screening of patients

a) There would need to be a clear sense of what interventions were appropriate for

each situation This would need to take into account

i) safety

ii) Timing: there are critical periods of opportunity and risk in development, each

dependent on the achievement of the preceding

iii) Individual factors (cognition, attitude, affect and behaviour)

iv) Peer factors (identity, belonging, resilience)

v) Socio-cultural, economic and spiritual factors. The fragmentation of communities

and alienation of people compelled to seek work in cities far from communal

support compromises psychosocial resilience and exaggerate vulnerabilities.

People may be stigmatised because of being refugees, sexual orientation, or

because of genetic or chromosomal abnormalities or other alienating features

that limit access to community and support. These need to be catered for in

interventions. There may be a need to access resources which support the areas

of basic community safety of Policing, justice, religion, media.


vi) Materially, poverty and geography can limit access to resources. It may be

important to cooperate with agencies which provide training and opportunities

for income generation. These need to be documented (by researcher?)

vii) Certain medical diagnoses may need special consideration and accommodation,

for example individuals or family members who are HIV positive or terminally ill.

All of these factors determine mental health status and guide a radiation of intervention

strategies which may require different role-players. These would need to be mapped

out.

4) Which health provider? there would need to be consensus regarding the competencies

required to deliver these and a set of expectations regarding ongoing training, support

and supervision that providers should receive. For each category there would therefore

need to be consensus regarding :

a) skill sets

b) levels of education

c) ongoing training, support and supervision

5) Set up health teams

a) Include as many group variables as possible.

6) Supervision should not only be used as a monitoring and protocol-adherence tool.

Reporting supervision content and procedures, as well as by whom supervision is

delivered, will answer key questions about the role that specialists might need to play in

an integrated service. Ensuring that providers are emotionally contained and supported

in their work will deepen the work and personal life of the role-player. We all deserve

health.

7) How would such an intervention look?

This table is structured on a continuum of indirect direct intervention. It also considers

the economic value of media intervention, groups vs individual etc. One could also stratify it

in terms of cost, one to one contact would be the most expensive whereas podcasts

(indirect) shared with groups, for instance, might be less expensive. See table overleaf

Structural (advocacy, awareness, discussion and Psychoeducation)LegalFinancialReligious


CommerceEducational institutionsChildcare institutionsGovernmentMediaResearchPersonalMost indirect:Support and enablement of healthcare staff (primary care, community workers) - caring for the carers, consultation on complex cases, supervision, training.

This can be in person, virtual (skype etc) or written material. It can be done by facilitating supervision groups or one2one.

Less indirect:Behaviour change (indirect service): Patient change (eg NCDs, treatment compliance, Psychoeducation, early detection, stress reduction, lifeskills, stigma reduction.

As above this can have a similar range of methods. The area of Health Psychology has a body of research around what brings about safe-sex behaviour treatment compliance in HIV, for instance.

More direct contact Counselling (validation, witnessing, referral, advice, CBT)

This could be done by Psychoanalytically informed lay counsellors (the entry level Psychoanalytic practitioner (PP)

Direct contact: Psychotherapy1. Peergroup work2. Individual psychotherapy (here we need

to specify our interventions, proposed treatment protocols, etc.)

This could be done by our membership in many paradigms, doing work with individuals, couples, groups and organisations

Psychoanalysis

Historically various stratified models have been proposed in public health. I am not an expert

on public health but I do know the division of public health into primary, secondary, tertiary

model of health where “Tertiary care is specialized consultative health care, usually for

inpatients and on referral from a primary or secondary health professional, in a facility that

has personnel and facilities for advanced medical investigation and treatment, such as a

tertiary referral hospital.” These models could be adapted and integrated.I think that a strong

case needs to be made for the difference between symptom alleviation and prevention. There

are also models of Primary, secondary and tertiary prevention

(https://www.iwh.on.ca/wrmb/primary-secondary-and-tertiary-prevention)

The adoption and support of such an integrated approach would require authorities to bypass

short-termism and to choose the longer (less-sexy) route of investing in the long-term


structural well-being of the country. In this way, rather than being a mere constitutional

entitlement, human rights are redefined and implemented in direct relationship to National

Mental Health.

As a primary point of entry strategies would need to cover the following areas:

promoting a culturally sensitive, safe and supportive environment;

providing information

building skills

basic counselling

access to health care services

A secondary point of entry would be involved in structural changes on both the collective

and the individual levels. It is here where the value of the Psychoanalytic method becomes

apparent. With its much-researched understanding of the impact of history and community

on the developing adult the Psychoanalytic approach is well-placed to collaborate with

other parties in intervening structurally at both individual and social levels.( In this way

Psychoanalysis returns to its roots and mental health again becomes a human rights issue

and a service for all.)

On a collective level a co-operative strategy would research and intervene in

terms of the often underestimated impact of society on the mental health of certain

populations, groups and individuals. For many years many organisations and projects have

been working hard at this level. In the last few decades health issues have become more

and more of a rallying point for social change. Role-players have been involved in the

advocacy, lobbying and psychoeducation of community structures influencing amongst

other things:

Representation: in media and advertising, as well as by authority structures

(government, communal education and religious structures), focussing particularly

on those messages which alienate individuals and therefore fragment social support

(e.g. prejudices regarding gender, sexual orientation, Fathering, the stigma around

Psychiatric illness)


Legal issues: drawing attention to laws which obstruct an individual’s capacity to

heal and integrate meaningfully into society (e.g. paternity leave, school uniforms

for LGBTI learners, safe living areas, accommodation proximate to resources, safe

transport, conditions in psychiatric hospitals etc.)

Funding: advocating the funding of programmes by government, Private-Public

Partnerships and foreign donors (e.g. a collaborative effort on prioritised issues like

early infant development, trauma, HIV, substance addiction)

Commerce: The greater range of this mental health model would then see basic

human rights issues included in its scope, so that, for instance, access to safe

accommodation, nutrition, sanitation would be seen clearly as being an important

mental healthcare issue as well as a basic human right. The relationship between

human rights and health would need to be emphasised and the statistical models of

monitoring and evaluation efforts would need to take into account longer- term

measures of efficacy as well as being able to assess and anticipate communal health

challenges.

Employment: promoting employment opportunities and practices which support

mental health of all. These industrial issues relate directly to the safety and health of

an environment and its individuals. Issues like “a living wage”, education,

internships need to be seen as important mental health issues and worthy of

research, debate and advocacy.

Research, evaluation and Monitoring: constant research, evaluation and

monitoring of national and international mental health models and structures (a

collaborative effort by tertiary education institutes to help in this regard and to

input directly)

On an individual level structural changes would be approached in a similar polyvalent

approach, seeking to research and influence an individual’s unacknowledged

unconscious motivations. Like the advocacy and lobbying at a structural collective level,

such individual structural work is also widespread in the country with many professional

groups working in a spectrum of Psychoanalytic modes. Research has clearly

demonstrated how such work can influence deep patterning like attachment styles,

impulse control, distorted thinking and defence mechanisms. By working alongside a


social action approach the Psychoanalytic approach extends beyond mere symptom

relief addressing structural impacts rupturing individual and communal integrity. This is

where psychoanalytic work extends beyond mere health concerns and becomes the

work of human rights. This systemic approach has been used by others to good effect

(Richter, Triangle, Rape Crisis, Sinani etc.) and been shown to promote health and

prevent relapse not only in the individual but also in the community.


file · web viewthe study makes controversial claims but ones that go to the heart of the debate...

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