The 5 As: A checklist to step up for mental health

By Suntosh R Pillay

It’s no secret that mental health has always been the Cinderella of the health system: locked up in a dark basement hoping never to be found. Or, when mental health does get a few good moments in the limelight, like Cinderella’s carriage it turns into a pumpkin at midnight and becomes old news by the morning. Unfortunately, even our fairy god mothers have failed to impress – neither the long awaited Mental Health Care Act in 2002 nor an impressive national policy framework and strategic plan that began in 2012, have resulted in significant change. The magic wands appear to be elusive. The National Health Insurance (NHI) is also thin on details about the implications for mental health. After all, the National Department of Health spends only about 4 percent of its budget (R9.3 billion) on mental health.

As such, the dominant discourse in global mental health right now is a concept called task-shifting – which means shifting specialised tasks that psychiatrists and psychologists would do with patients and breaking them down into smaller, more manageable tasks that could be performed by lower level workers in the health system. Studies abound about the benefits of task-shifting – or task-sharing – and its reported success in low and middle income countries. It’s a realist, pragmatic approach to addressing the burden of mental illness on the public health care sector – after all, at our current training, graduation and public sector employment rates, we’re never going to have enough specialists to go around.

At a broader level, task-sharing also demands that all of us – the public included – become advocates and enablers in the promotion of positive mental health and prevention of mental illness. Along these lines, the global theme for 2016, set by the World Federation for Mental Health, is Psychological and Mental Health First Aid. This catchy concept of “mental health first aid” means that the public should be able to deal decisively in the case of a psychological emergency, in the same way that you’d know what to do in a medical emergency of someone choking or needing CPR.

What do you do, for example, if a friend phones you to say that he is suicidal? Or if you find your teenager slitting her wrists? Or if your brother gets aggressive and dangerous at a party? Or if your son is threatening to run away from home? Or if a student in your class has a panic attack? Or if a colleague has a manic episode at work? What do you do? These are the kinds of scenarios that warrant all of us to be skilled in responding effectively and empathically to the person in need in the heat of the moment, before a professional person can intervene. In this way, mental health becomes everybody’s business (which in communal interdependent societies, like South Africa, ought to be the norm). It is culturally appropriate therefore, that communities take back their responsibilities to each other, because positive mental health is rooted in a sense of belonging to a larger social group.

In order for this to happen, there is an enormous amount of legwork required and is currently being done by research groups and advocacy groups. To simplify the agenda, I suggest that we adopt a simple five point plan (the 5 As) as a checklist of our progress, focusing on Attitude, Awareness, Assets, Access, and Action.

1. Attitude
Our attitudes to mental illness must change. Stop using words like psycho, crazy, mad, stupid, off your head, and other offensive and stigmatizing phrases that make it difficult for people with mental illness to be open and honest about what they are experiencing. Health professionals, too, need to destigmatize their own language and attitudes. Sometimes these myths operate more benignly, like believing that mental health conditions always require specialized or institutionalized intervention, rather than being treatable at a community or clinic level. Professionals also need broader and deeper access to mental health care training and skills development, especially communication and basic counselling skills.

2. Access
The public needs smooth and efficient access to health care facilities and information and access to life-changing medication and psychotherapies that can prevent symptoms from becoming disabling. The implementation of a United Nations-endorsed project to get 90% of the population tested for HIV, on treatment and virally suppressed is being expanded to include common mental disorders in some provinces in South Africa, such as KwaZulu-Natal. This means setting a far more ambitious agenda for the number of people being screened and treated for mental illnesses.

3. Awareness
A long overdue national mental health awareness campaign is on the cards. People carry around astoundingly ignorant beliefs and misconceptions about what mental illness is; or are unaware of the different roles of psychologists, occupational therapists, social workers, psychiatrists, counsellors etc., or the usefulness of medication, psychotherapy, support groups, etc. There are creative examples to draw from, such as the use of art and drama at grassroots level, the development of a mental health app., the #DignityInMind Film Festival in Cape Town, or the newly formed KZN Mental Health Advocacy Group that I am involved in.

4. Assets
An overlooked component is an appreciation of the assets in communities. We need to strengthen what works, build on social capital especially in the absence of financial capital, drawing from the rich communal traditions that define Ubuntu in a South African context. Research shows over and over again that supportive and empathic relationships are the foundation to mental wellbeing. We need to start asking communities different types of questions in our research, such as ‘what works?’

5. Action
A lot of the right words have been written and spoken, but action is what’s needed. This includes – foremost – political will to create and fill posts at all levels, to train and capacitate people to deal with mental health, and to fulfil the promises laid out in policy rhetoric. This also requires communities and individuals to reasonably and ethically take mental health into their own hands – such as the Bessie Makatini Foundation – and to help change attitudes, create awareness, strengthen assets, demand better access to services, and ultimately be action-oriented advocates for change.

Cinderella waits with hope for the glass slippers that finally fit.

Suntosh R Pillay is a clinical psychologist at a public hospital in Durban, King Dinuzulu Hospital Complex. He chairs PsySSA’s Equity & Transformation Committee and is vice-chair of the Division for Community and Social Psychology (CaSP). In 2015, he was named one of the top 200 young South Africans in health care by the Mail & Guardian newspaper. To connect, tweet @suntoshpillay or email [email protected]