A unique initiative aims to empower communities to create care, employment and include those with mental health illnesses in society in Ghana. Tony Batesvisited there to see what lessons can be learned
Conversations about mental health inevitably focus on the problems experienced by individuals and families who find it difficult to access effective support when they need it most. Service inadequacies are highlighted, and rightfully so.
The remedy proposed for these inadequacies is generally along the lines that the Government should deploy more funds to create more professionalised services. And here the conversation seems to stop.
I am increasingly uneasy about this line of argument but I've never found it easy to articulate exactly why. Services are vital to make available the expertise that people may require to support them through severe mental crises.
Sustained recovery, however, needs something more. It requires that people are supported in developing and expressing their talents and skills. It is through contributing to their community and being valued - basic needs and basic rights for every human being - that people recovering from illness can feel that they belong.
We could say this should be the responsibility of services, but perhaps it is time that communities are empowered to take ownership of their role in this process.
I visited Ghana recently to experience BasicNeeds, an organisation that adopts a community oriented, rights-based approach to mental health. BasicNeeds works with people so afflicted with severe untreated mental disorders that they often end up chained with manacles, abandoned and marginalised.
It works with communities to make them aware of the neglect that mentally ill people and their families experience and to work together to turn this situation around.
BasicNeeds believes it is only communities - empowered and supported by services - that can right the wrongs inflicted on the mentally ill through stigma and social exclusion.
And, in doing this, a community rediscovers its own heart. Theirs is a mental health and development model that seeks not only recovery in the community for those with mental illness, but recovery of the whole community.
The BasicNeeds model is being delivered in nine developing countries, to 41,000 people with severe mental illness and five times that number of families and carers.
Chris Underhill, its founder and director, established this organisation in 1999 to counter the social exclusion of those with mental illness.
He saw marginalisation as a consequence, not only of people's illness, but also of their poverty. These two factors work together to isolate and, in Underhill's view, "attention to both is crucial".
In a family struggling with poverty, everyone's contribution is valued. When someone in the family can't work because of mental illness or the stigma attached to it, they are immensely vulnerable to being devalued or even abused and abandoned.
Communities in northern Ghana traditionally restrain the mentally ill by chaining them to an outhouse with iron manacles - a practice that still pertains in remote villages. Where these individuals escape these chains, they invariably end up homeless in major cities.
During my visit I helped out in the daily ritual of feeding 150 "mentally ill destitutes" from the back of a pick-up truck that drove around Tamale - this work was one part of a BasicNeeds outreach programme.
The BasicNeeds model is a four-phase programme that addresses both lack of treatment and unemployment in ways that mutually reinforce inclusion and wellbeing.
When they began work in northern Ghana, in 2002, Underhill and his associate, Lance Montia, conducted a number of day-long consultations in different locations, deep in the African bush territories.
Hundreds of people turned up from the surrounding villages and gathered together, often under the shade of trees.
The consultation phase involved separating the gathering into three groups: those with mental illness; families and carers; and health workers and traditional healers.
Each group was facilitated in articulating how they experienced "their world" and presenting this to the others. For many of the mentally ill, it was the first time they had ever spoken about their lives and the first time they had ever been listened to.
All of these meetings were documented and the expressed needs of all the groups became a basis for developing a strategy that could work for each particular community.
The second phase of the BasicNeeds model is to build partnerships with existing organisations in villages and surrounding communities to increase their capacity to respond to people with mental illness. From their consultations, they learned that the primary need of the mentally ill was access to mental healthcare in their communities.
BasicNeeds established key partnerships with healthcare providers - including district nurses, trained volunteers and disease control workers - and trained them to deliver a new model of community healthcare.
They also funded psychiatrists from Ghana's capital city Accra to fly to northern Ghana monthly and provide medical care in field clinics. Provision of basic medications made an enormous difference and allowed families and communities to dispense with iron manacles and to trust the mentally ill to participate in village life.
I was struck by the fact that, due to cost factors, only two medications are employed for mental illness: Largactil for those with psychosis and Tegretol for every other syndrome (of which epilepsy is the predominant disorder).
The stabilisation that was achieved through providing medical treatment for the first time, along with the support received from the self-help groups, enabled BasicNeeds to move into the third phase of its model: sustainable livelihood.
Once people became stabilised they wanted more - they wanted and needed meaningful work so that they could make a contribution to their community and experience self-respect.
The BasicNeeds programme took care to identify each person's unique capability and return them to former employment or train them sufficiently to start their own small businesses.
Funding for this phase was raised through establishing partnerships with micro-credit agencies and persuading them to extend loans to the mentally ill. These loans were small to begin with and they were given to groups of 10 people who took collective responsibility to pay them back.
Nothing like peer pressure to encourage fiscal responsibility.
Training and employment opportunities were also accessed through the partnerships with local traders and farmers. These partnerships were backed up with a small amount of funding, training and memoranda of understanding in respect to how the mentally ill were to be integrated.
Horticultural therapy is also provided to support the recovery of the mentally ill and to equip them with a marketable skill so that they can secure productive employment.
The final phase of the BasicNeeds model is research and advocacy. All their sites throughout the developing world are carefully evaluated and findings are used to influence local and national health policy. Advocacy on behalf of the mentally ill is core to their model.
Currently in Ghana, they are working to foster leadership among the mentally ill themselves, so that they can directly represent their own needs and rights to regional and national government agencies.
From its first meeting in northern Ghana in 2002 with 100 people gathered beneath a banyan tree, the BasicNeeds programme has grown to include 14,000 mentally ill people and their families, who are integrated within their communities.
In small village communities dispersed across the northern territories these people gather weekly in one of 41 "self-help cells".
I was driven across the wildest of terrain to meet and listen to several of these groups. We sat together in shaded spaces at the heart of the community and they spoke with pride of how far they have journeyed since the days they were chained and hidden away.
I have never experienced a group of severely mentally ill people who have come so far in their recovery. Their appreciation for all the support they had received was moving. And their joy at belonging and contributing to their families and communities was infectious.
Their meetings began with a prayer and ended in singing and dancing.
They embodied recovery, a recovery they had achieved through their solidarity with one another and a range of interventions that had supported them along the way.
I was very moved by my experience of BasicNeeds in Ghana. It left me wondering can the people I met in Ghana teach us anything in this country? Could it be that people with mental illness can help us rediscover something essential about what it means to be a community?
There is a unique opportunity to hear Chris Underhill and Lance Montia speak about the BasicNeeds rights-based approach to mental health in the Writer's Museum, Parnell Square, at 7.45pm, Thursday, May 17th. Admission is free and all are welcome. For details tel: 01-7168410
Tony Bates is founder director of Headstrong. Contact: tbates@irish-times.ie BasicNeeds has a website: www.basicneeds.org.uk
The global challenge
Mental illness now accounts for about 12.3 per cent of the global burden of disease, and this will rise to 15 per cent by 2020 by which time depression will disable more people than Aids, heart disease, traffic accidents and wars combined.
The impact of mental ill health on the lives of huge numbers of individuals, their families and communities - not least in economic terms - is phenomenal. While this enormous health burden is increasingly being recognised, so too is the inadequacy of our global response to it.
In most countries, mental illness is simply not taken seriously. Forty per cent of countries have no mental health policy and 25 per cent have no legislation in the field of mental health.
As one might expect, services also show huge international variations: one-third of the world's people (33 countries with a combined population of two billion) live in nations that invest less than 1 per cent of their total health budget in mental health.
The availability of mental health professionals in large areas of the world is extremely poor. More than 680 million people, the majority of whom are in Africa and Asia, have access to fewer than one psychiatrist.
Chris Underhill, founder and director of BasicNeeds