Alternative Global Mental Health

Building social and emotional spaces into policy in Global Mental Health – what can we learn
from local grassroots organisations?


With the growing Global Mental Health movement increasingly wielding a model
based on the psychiatric and psychological paradigm that developed in high income
bio-medically driven cultures, is it time to question if this diagnostic and treating of
‘symptoms’ approach is what human beings really need? (Davies, 2014) There are
many stakeholders invested in the deployment of such a model, selling it to the
policy makers and implementers of low to middle income countries as a ‘human right’
to good mental health, but when we look at how this approach works in high income
countries, we see that there are many flaws which themselves generate many
unintended consequences, doing little to contribute to the long-term well-being of
individuals and societies.(Kirmayer, 2006, Summerfield, 2013, Davies, 2014, Hari,
2018, Patel et al., 2018) To my mind the argument against a full on implementation
of this model not only includes highlighting the arrogance of ‘western dominance’ or
‘psychological colonialism’, but also asks the question is this model helpful? And isn’t there a better way of enhancing the well-being of the global population?


There are vocal and powerful arguments around the subject of GMH across
academia, from within critical psychiatry, psychology, anthropology and the social
sciences in general. (Mills and White, 2017) At the grassroots level, service users
and experts by experience are advocating for services that better reflect their needs
(Beresford, 2016). Many activists are highlighting the importance of
abolishing/improving social, structural and political determinants that create the
conditions which lead to poor mental health, (Burgess et al., 2020, Beresford, 2020)
and so the fight continues, but have we lost sight of what life can be and what to aim
for by focussing on the many identified problems? There is something seductive
about focussing on problems, injustices, symptoms, and ills, which takes our gaze
away from potential and possibility. Therefore, this paper wishes to direct attention
instead to the topic of happiness and well-being. The focus of this paper will be on
short study of grassroots organisations across a selection of cultures. Each have
grown out of the identification of a need to approach mental health issues differently.
Through a brief examination of these thriving organisations and the environments
they create, I will attempt to elucidate the commonalities and universalities across
the organisations perceived through a ‘wellbeing lens’ (Thin, 2020) and also to
highlight some of the self-reported positive impacts of these organisations upon the
well-being of service users. The paper will then consider ways in which these
approaches could contribute to future policy making designed to positively impact the
happiness of people and societies. (Beresford and Alibhai-Brown, 2021) The aim of
looking at what is taking place in grassroots organisations is to dispel the notion that
well-being is just an absence of illness, or distress.(Seligman, 2008) and to
encourage future organisations and policy makers to aspire towards levels of well
being that are higher than beneath and up to the ok line for all human beings. (Thin,
2020)


There is not the scope within this essay to discuss the different philosophical
meanings of happiness and well-being, but as a reference point to underpin what this
essay is expecting to find in the fabric of the organisations explored, the following
description is useful. ‘Human flourishing is to a large extent comprised of
relationships, cultural processes, and institutions – not merely influenced by these.
Well-being must therefore be understood as a ‘public good’(Thin, 2020). It happens
not only at individual but at collective levels. We ‘live well’ not just in our minds and
our bodies, but in our relationships, and in our cultural heritage’(Thin, 2020). It is
ambitious to recognise that happiness and wellbeing across a lifespan is achievable,
but for some inspiration towards aspiration from the economist Mariana Mazzucato,
using the metaphor of the bold achievement of landing on the moon, she asks the
question – ‘How do we apply these same ‘mission’ principles to the most pressing
problems on earth today? – making sure the missions themselves are ambitious and
grounded in making the lives of people better’ (Mazzucato, 2021)


Culture and Well Being

A large amount of the critique around the Global Mental Health movement is
regarding a lack of acknowledgement of cultural differences across the globe. (in this
instance I use culture to mean geographical ethnicities, values and belief systems)
(Selin and Davey, 2012). There is concern that localised social and cultural sense
making of life experiences, as well as ethnocentric healing and spiritual practices will
be usurped in favour of pathologisation and disordering of emotional responses
(Kirmayer, 2004). I would like in this paper to instead explore the commonalities
around how ‘healing’ and ‘flourishing’ takes place in grassroots organisations and the
socio-cultural environments that they create. (in this instance culture meaning
relationship (co-creation, social goods, learning, development, connection,
expressivity etc) When looked at though a lens of ‘wellbeing’, what ‘public goods’
(Thin, 2020) are they generating that may have been missing from the lives of the
people who come to use their services? And how might recognising their universal
value help us to establish better opportunities for well-being through the inclusion of
these values in future policy making?


A brief look at three case studies of bottom-up, grassroots organisations.
Huertomanias
The grassroots project based in Ecuador named ‘Huertomanias’ which translates as
‘Garden Maniacs’ was created by a passionate individual with awareness of the stigmatisation,
marginalisation and exclusion which prevents people who are experiencing poor
mental health from engaging in the meaningful aspects of wider society. The project
was initially started as a means of offering employment to people with mental health
challenges, but blossomed and flourished into a service user led entity. People
participate in the co-creation and maintenance of a beautiful garden full of produce
they themselves plant and nurture, which is shared, and taken to market and sold for
profit by the growers. The participants of this social and natural environment also
make products and deliver workshops through which skills are developed,
relationships are formed, and interaction with the wider community is established.
Through this process of engaging people with people, people with nature and
nurture, and a sense of purpose, stigmas naturally subside and participation in the
wider social environment grows. People can move away from the labels that they
have been given and come to experience themselves and their lives as valuable.
They come to realise that they are in fact ‘men, women, friends, workers, mothers,
fathers, daughters, brothers, human beings’ again.(founder) Relationships with their
families change, they no longer need care, but are ‘part of’ a caring system where
care is exchanged with reciprocity The Heurtomanias refer to themselves as
‘workers’. There are no longer the labels that they were given through mental health
diagnosis. They are wholly and entirely more than that (Huertomanias,2021).

Burans
With a slightly different approach the ‘Burans’ project operating in Uttarakhand, a
remote territory in Northern India, works with mental health issues across
disadvantaged communities to promote well being by focussing on strengths and
resources for the good of the entire community. Again, this project involves fullservice user participation in the development of its projects, including the coproduction of visual communication tools, realist evaluations, group facilitation and
community engagement. This project does include increasing access to mental
health services where required but takes an approach that involves helping people to
develop their social and participatory skills through games, role play, discussion,
dance, and community activities. People report feeling increased engagement with
their families, friends, communities, and those who have been previously
marginalised report re-establishment with community environments including
education, temples, and wider relationships in general. The Burans project has close
ties with the University of Edinburgh and carries out Realist Evaluation forms of
research offering a qualitative insight into the experience of participants. The
research is also co-developed and carried out by experts by experience and local
community workers (Mathias et al., 2020).


Iswar Sankalpa
Iswar Sankalpa is a slightly different organisation. It is an NGO but began as a
bottom up service. The founders identified the need for this service when they
observed the extreme marginalisation of homeless people in Kolkata with psychosocial disabilities. The tone of the language in the project literature has a far greater
psychological bent to it, but that said, its focus through its evolution has been to
create environments in which people can heal, and ultimately thrive. They have
different services for different needs but offer the basics of unconditional positive
regard towards service users, in the form of whatever assistance the person feels
they need, be it a shower and clean clothing, or access to medical treatment. The
surrounding community is also solicited to engage in a level of social support for
individuals that prefer to remain on the streets and may not feel ready to engage with
further assistance. The services offered usually begin at this low-key level to allow
trust to build slowly. The levels of exclusion experienced by people with ‘psychosocial’ disabilities in Kolkata can lead to extreme deprivation, so a certain amount of
primary level care takes place before social and rehabilitative environments are
sought as a hierarchy of needs are first to be met. Once the social support is
accessed it is in the form of creating community though access to skills building,
supportive employment and community integration of many varieties. Engagement
with agricultural work and animal husbandry is available, as well as a community
café where women who have experienced violence can come together to train in
cookery skills while they socialise and establish and strengthen social ties in a safe
space. The whole environment offers a convivial approach, allowing the
development of well-being, resulting in some cases with reconciliations with family,
friends, and the forming of new relationships. Support is maintained for as long as it
is needed. At a slightly more macro level, those running the organisation are also
benefitting from the increased connections through the collective engagement of
community members, other organisations and through the ongoing collaborative
research projects it carries out (Iswar,2021).


What commonalities are found when these organisations are observed
through a ‘well-being lens’?

The commonality of these projects is that they aspire to more than just an up to the
‘ok line’ set of expectations. (Thin, 2020) They have been established with an
awareness of the importance of creating environments in which people heal, and
further, thrive. (Thin, 2014) Unlike models that aim for below the ok line (Thin, 2020)
(which are often about symptom and harm reduction), what is built into each of these
organisations is an understanding of how well-being and happiness are socially
interactive, integrative, ongoing, and cumulative processes. There is an aspiration
that the people who come to these organisations for assistance are as able to
embark on and engage with their own journey towards a happier and more
meaningful life as anybody, given access to a hospitable environment, alongside
social opportunity, and support. (Huertomanias, 2021)


Poverty, violence, discrimination, stigma, and marginalisation are identified as
contributary factors which appear to be universally disruptive to well-being for
obvious reasons. (Burgess et al., 2020) Transcending causal factors for the
purposes of aspirational focus, each of these organisations (though it is only a tiny
sample of grassroots expert by experience led services being over-viewed) though
conscious of the problems choose to pivot their focus. Their emphasis and energy go
into the creation of socially supportive environments underpinned by unconditional
positive regard, service user participation and co-created aspirations towards better
lives. Of the ‘Four Qualities of Life’ identified by Ruud Veenhoven (Veenhoven,
2015) all of these organisations offer firstly an ‘environment of liveability’ which is
conducive to human well-being. Secondly service user participation and inclusivity is
also an important aspect when it comes to the development of a sense of well-being.
(Beresford, 2016) Ethically and morally, to include people in the co-creation of their
lives restores dignity and autonomy and offers a mutually valuable exchange of twoway knowledge, experience, and energy. (Beresford and Alibhai-Brown, 2021) The
WHO recognise service user participation as an essential contribution to the cocreation of knowledge (Patel et al., 2018) and although it so far in the large top-down
GMH projects been fairly tokenistic, that it is acknowledged and desired is a starting
point (Ryan et al., 2019). In a recent conference on Social Change and Mental
Health – Shifting the Narrative conference, Akiko Hart, the CEO of the National
Survivor User Network spoke of policy makers still seemingly disconnected from how
to include participation by service users in policy, despite it being considered integral
to the quality and appropriateness of services delivered. Her belief is that the change
will come from the grassroots organisations demonstrating the way forward through
good practise and research (Hart, 2021).


Building and sharing knowledge through participation and inclusion enhances life
skills, autonomy, and increases empowerment (Beresford, 2016) which could fit the
term used by Veenhoven as contributing to an improvement in ‘lifeability’.
(Veenhoven, 2015) An improvement in valuable life skills developed through
participatory experiences could help to contribute to greater future engagement in
relationship to the world and therefore greater wellbeing. (Thin, 2020)
All the projects allow opportunities to create and contribute to both the organisations
themselves and to the wider community in the form of peer support, skill learning and
sharing. This approach again, enhances a sense of contribution and usefulness,
which Veenhoven identifies as another of the ‘four qualities of life’ (Veenhoven,
2015). These three components may or may not have been built into the
organisations explicitly, but nevertheless the evaluations of each service and the
service users self-reported well-being reports amount to a report of increased ‘lifesatisfaction’. (Veenhoven, 2015) Using this knowledge as a starter point to encourage a ‘happiness lens’ shift in policy making.


If we can see that grassroots organisations are able to create environments in which
people are able to heal, and more, thrive despite their experiences of poor mental
health, is there an argument for taking the therapeutic components of these services
and actively creating them for more and more people? Instead of waiting until people
are suffering, to instead put time and energy into creating environments in which
people can thrive in the first place? There are many opportunities to do this
throughout the lifespan (Thin, 2020), so how can we persuade policy makers of the
importance of this? If we are looking at psycho-social well-being as a human right (Patel et al., 2018)
should not we be building into policy the human right to thrive in an environment
conducive to the generation of well-being in the first place rather than only
emphasising the human right to access remedial treatment when things go wrong?
How can we better use the research from these projects to inform better policy?
Given that the organisations are evolving from the ground-up and organically
demonstrating their benefits would it be beneficial and more meaningful for policy
makers to engage with their findings, not just quantitatively but qualitatively? (Thin,
2012). This may help to resolve the disconnect observed by Akiko Hart by engaging
those involved in policy making more empathically with the social and environmental
requirements that lead to well-being. This approach may also help to bring about an
increase in co-creation between organisations, further generating social collaborative
working across sectors, reducing separation and expanding inclusivity. (Beresford,
2016)


Could larger international organisations such as the WHO, United Nations and the
Global Mental Health movement use their positions to help to facilitate such multidirectional and multi-sector support, by encouraging structural and legal frameworks to underpin a compatible bottom-up, top-down two way flow of research informed
knowledge building? This would move away from the currently criticicised top-down
structure and it’s many downsides including cultural inappropriateness,
psychologization and over-medicalisation of human challenges, so that there can be
a shift towards using a broader bottom up knowledge base to underpin improvement
of social and environmental conditions for people instead? (Mills and White, 2017)
From the small snapshot of grassroots organisations highlighted, their benefits seem
to support the notion that happiness is not just found in social relationships, but is
also found in the quality of relationship with nature, productivity, inclusion, purpose,
skills, society and more. (Thin, 2020) In each of these organisations there is a focus
on and an appreciation for what Neil Thin describes as ‘appreciative empathy’, the
sharing of one anothers achievements, joys and well-being. (Thin, 2014) Knowing
that it is possible to create these environments in the direst circumstances of human
suffering, must surely demonstrate that such environments could be formed
elsewhere, for the good of mankind? Scaling up,Task Sharing’ and addressing the
Treatment Gap are the ‘Grand Challenges’ for GMH (Patel et al., 2018), so is now a
good time to shift focus to greater investment in global wellbeing and happiness as a
long-term investment in not only the human race but the planet as a whole, before we ‘scale-up’ a bunch of damaging, culturally inappropriate, disorder based philosophies and treatments into the so called ‘gap’?


To conclude – there is much research to be done in this area. Much work in GMH
prioritises evidence-based research to establish and then scale up primary care
approaches and symptom treating (Kirmayer, 2006), or is focussed on reducing
social and structural causes (Burgess et al., 2020). Grassroots organisations are
responding to need and growing in both service provision and influence to create
better conditions for people. They face many challenges, such as short-term funding,
sustainability issues and research deficits, but we are seeing human beings creating
environments for healing, growth and engagement (Ember, 2021), surely a more
natural process to ‘scale up’? Longitudinal studies of many varieties from all
disciplines would be ideal at this stage to capture a fuller picture. Now while still at
the early stages would be a good time to begin. Greater collaboration, a higher
vision, and going beyond the limitations of the ok line are possible, and desirable and
attainable. (Thin, 2020)


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