Abstract
FO01 RECOVERY, RESILIENCE, AND A PSYCHIATRY FOR THE PERSON – CONSEQUENCES AND CHALLENGES OF A PARADIGM SHIFT
Michaela Amering, Margit Schmolke, Carol Harvey, Michael Krausz, Levent Küey, Helen Glover, Juan Mezzich, Jenny Burger
CONSEQUENCES AND CHALLENGES FOR CLINICIANS-‘BRING THE JOY BACK TO WORK’ (C. HARDING)
Michaela Amering, Margit Schmolke
While much of recovery is lived outside clinical settings there clearly are important responsibilities for clinicians in supporting and assisting persons with mental health problems in their efforts towards making full use of their health and resilience, and achieving their goals in life.
Moving beyond a deficit model of mental illness to including a focus on health promotion, individual strengths, and resilience, a shift from demoralizing prognostic scepticism towards a rational and optimistic attitude towards recovery, and broadening treatment goals beyond symptom reduction and stabilization need specific skills and new forms of co-operations between clinicians and patients, between mental health workers of different backgrounds, and between psychiatry and the public.
The emerging evidence-base for recovery-orientation includes the urgent call for a partnership approach allowing the full involvement of clinicians and patients as persons beyond role stereotypes. Patient self-determination, individual choice of flexible support and opportunities, interventions to promote empowerment and hope also in the long-term, as well as assistance in situations of calculated risk are new indicators of quality of services.
Cooperative and coordinated efforts together with consumers, carers, their spokespersons and public health advocates offer formidable chances to reduce stigma, discrimination and social exclusion, currently seriously limiting clinical and other efforts towards recovery.
While the task appears huge, the combination of the wisdom and energy of the consumer movement and the current need of many clinicians-and academics-in psychiatry world-wide to overcome reductionistic and uninspired conceptual frameworks might just work in favour of substantial changes now.
RECOVERY FROM MENTAL ILLNESS REQUIRES SOCIETAL AS WELL AS INDIVIDUAL CHANGE: CONSEQUENCES AND CHALLENGES FOR POLICY MAKERS
Carol Harvey
EVIDENCE, ADVOCACY, PARADIGM SHIFT – CONSEQUENCES AND CHALLENGES FOR RESEARCH IN A DIFFERENT ROLE
Michael Krausz
For the future of medicine, its failures and success, research plays a key role. Also for the success of any paradigm shift. But it is not only about evidence it is also about values and the role of research in the development of the health care system. Role means also to redefine the relationship between the acting subjects in Psychiatry. User involvement is one key approach, asking patients about the importance of questions, seeing them also as active subjects in the world of science, treated with respect, interest and curiosity. But also the distribution of resources in the system of research has to change along changing paradigms. This system is defined by its resources, either as clinical neuroscience or integrated human science.
PSYCHIATRISTS ALSO NEED HOPEFUL PERSPECTIVES: CONSEQUENCES AND CHALLENGES FOR EDUCATION
Levent Küey
Education in psychiatry should be formed considering the desired identities of a psychiatrist. The data provided by the Atlas Project of WHO-WPA on Psychiatric Education and Training across the World (2005) suggests that current psychiatric training mainly reflects the application of medical model in psychiatry. Generally, it aims to produce a psychiatrist skilled in observation, description, explanation and treatment of mental disorders. The clinical practice of such a psychiatrist is restricted by a linear perspective concentrating on symptoms for a diagnosis, where diagnosis nearly meant prognosis and treatment. So, desired competency of a clinician is reduced to detect psychopathology and to give the optimum treatment, frequently medication. Thus, psychiatrist, through this process, usually “observes pathology and imposes treatment”, and the person who presents for care becomes “an object of treatment in a passive recipient role”. Furthermore, such an authoritarian reductionistic perspective, rather than an integrative approach including actual involvement of the person, also seems to contribute to the high rates of non-compliance in psychiatric treatments and poor outcomes, generating despair on both sides. On the contrary, current insight of recovery and resilience movement promotes collaborative roles aiming a joint clinical management process. Education in psychiatry needs to be revised to incorporate these new hope triggering perspectives among the desired identities of psychiatrist. This presentation will briefly mention the challenges for the current education and training curricula in psychiatry put forward by this paradigmatical shift.
PROFESSIONAL AND LIVED EXPERIENCE CONSTRUCTS OF ‘RECOVERY’: ARE WE ALL TALKING THE SAME LANGUAGE
Helen Glover
The knowledge base that strongly informs recovery and recovery based practice stems from those that have struggled and triumphed over their own experience of mental illness/distress. In recent years most mental health sectors and mental health professionals have claimed a recovery orientedness in their approach. Undertaking a recovery paradigm shift within service delivery is far more than a simple name change to existing practices. It requires a reorientation to every aspect of service delivery especially in relation to how providers, those who access mental health services, and their families understand their role within this new era of psychiatry. The effort required by an individual in their recovery process cannot be overstated. A recovery oriented era needs to provide many more opportunities and responsibilities for people to be active in their care, to extend their self management strategies and to develop and utilise their knowledge of what works and what doesn't. This in itself is a challenge, as many people have not had expectations or opportunities to draw on their own internal efforts of recovering, as much as relied on the expertness of others to ‘recover’ them. The re-orientation for professionals and services in their effort from ‘managing illness/distress’ to ‘supporting a person to managing their distress’ can also not be overstated.
FO02 MENTAL HEALTH ISSUES IN DISASTERS
George Christodoulou, J. K. Trivedi, Preston Garrison, Juan Mezzich, Russell D'souza
A Disaster is “a severe psychological and psychosocial disruption that largely exceeds the ability of the affected community to cope” (WHO, 1991). The severity of a disaster is thought to be associated with whether it is a natural or a man-made disaster (although this differentiation is questionable) on whether it occurs in a developing or a developed country and on a variety of other factors. It has a very serious negative impact on social structure and a variety of psychosocial consequences.
This Forum will deal, among other issues, with the predictors of psychopathology, the post-disaster psychopathological manifestations (with special emphasis on PTSD and acute stress reaction (ASR) and with the role of mental health professionals. Furthermore, the response of various mental health organizations to the recent disasters that have occurred in various parts of the world will be discussed and the contribution of the relevant structures of the WPA will be mentioned.
Disasters will always be with us. We must be prepared to face them and deal with their psychosocial consequences at any time. In order to be productive we must collaborate with others, assist (and not try to replace) the local governments and professional associations and take into account the cost/benefit parameter. Diachronic and not paroxysmal involvement with disasters is necessary. Specific proposals by the Forum participants will be made. More specifically, the proposal of the WPA Institutional Program on Disasters that some facilities in each country should have a dual function (in time of “peace” function as ordinary mental health centers and when a disaster strikes serve as specialized disaster intervention facilities) will be discussed.
Among the many negative aspects of disasters there may be one which is positive and this is the notion that a disaster may enhance a new vista of the world and a sense of purpose that may open new opportunities. This idea opens an optimistic window in an, otherwise, very gloomy landscape.
DISASTERS AND THEIR PSYCHOSOCIAL CONSEQUENCES
George Christodoulou, Angeliki Christodoulou
For every physically damaged individual there are three psychologically damaged ones. Yet, attention to the psychosocial needs of survivors is minimal. This has been the basic motive for the creation of the WPA Institutional Program for the Psychosocial Consequences of Disasters.
According to the definition of WHO (1991) a disaster is a severe psychological and psychosocial disruption that largely exceeds the ability of the affected community to cope. On an individual basis, however, a disaster is an event that produces a lot of suffering, has severe psychological and psychosocial consequences, may produce psychopathology and certainly aggravates pre-existing psychopathology.
The differentiation of disasters to man-made and natural disasters is uncertain as there is always a human contribution to natural disasters but the former have more frequent and more persistent psychosocial consequences. These consequences are thought to be more serious when a disaster occurs in developing countries where the human contribution is believed to be more pronounced.
This presentation will deal with the predictors of psychopathology in disasters, with the various clinical expressions of post-disaster psychopathology and with the role of mental health professionals in the management of the psychosocial effects of disasters. Furthermore, the response of the World Psychiatric Association will be presented, with special emphasis on the activities and perspectives of the WPA Institutional Program on Disasters. Some organizational suggestions related to the problem of management of disaster situations will also be discussed.
TRAINING ISSUES OF PARAMEDICAL STAFF: FOR CRISIS MANAGEMENT
J. K. Trivedi, P. K. Dalal
Mental health services depend largely upon the existence of a skilled, knowledgeable and committed workforce. It should be planned in advance for the crisis period, since available resources can better be allocated before the crisis strikes the community. Mental health workers are nowadays increasingly aware of the necessity to be equipped with the abilities required in effective crisis interventions since the world is becoming more insecure in terms of traumatic life events. People are struck with either man-made disasters, such as terrorist attacks affecting thousands of people, industrial accidents and war, or natural disasters, such as earthquakes, floods or tornadoes. They undermine the material and moral resources of the whole community, affecting the social structure, leaving the survivors under a greater risk for potential psychiatric morbidity (Ursano et al. [1995]). Medical and paramedical workers can combine efforts successfully to provide a disaster recovery response that is grounded in crisis theory and intervention techniques.
Training and education are fundamental strategies in preparing countries to provide psychosocial care, especially during crisis. It is essential to maximize skills and effectiveness. Many survivors of traumatic experiences suffer not only from the stress-related syndromes but also from depression, alcohol or drug abuse or personality disorders. Mental health workers can be trained to identify the new problems, which include all the ranges of depression, anxiety and post-traumatic stress disorder (PTSD).
THE DISASTER RESPONSE INITIATIVE OF THE WORLD FEDERATION FOR MENTAL HEALTH: SUPPORTING GRASSROOTS MENTAL HEALTH NON-GOVERNMENTAL ORGANIZATIONS TO MOUNT COMMUNITY-BASED RESPONSES TO DISASTERS
Preston J. Garrison
The WFMH Disaster Response Initiative was established by the Board of Directors following the December 2005 Indian Ocean earthquake and tsunami. Modest funding from the Initiative helped grassroots mental health organizations in India and Sri Lanka respond to the mental health consequences of that major disaster. The WFMH Disaster Response Initiative has a dual charge: (1) to seek opportunities and means to provide direct assistance to WFMH member NGOs based in disaster zones that are providing mental health assistance to victims and relief workers; and (2) to prepare member organizations to respond to the mental health consequences of future natural and manmade disaster situations. The purpose of this Forum is to explore opportunities to broaden the work of the WFMH Disaster Response Initiative and to promote a higher priority for the inclusion of appropriate mental health responses in disaster planning and humanitarian relief services.
This presentation will describe the WFMH Disaster Response Initiative will:
Provide an overview of WFMH's collaboration with SEVAC, a Calcutta, India-based mental health NGO, Provide early response and continuing mental health services to the citizens of the Andaman and Nicobar Islands following the South Indian Ocean earthquake and tsunami, and Outline WFMH's future plans in the area of mental health response and consequences of disasters.
FO03 MENTAL HEALTH POLICIES IN LOW AND MIDDLE INCOME COUNTRIES
Vikram Patel, R. Thara, Javier E. Saavedra, Oye Gureje
This symposium will provide a critical overview of MENTAL HEALTH policies in three low and middle income countries of the world, namely Peru, India and sub-Saharan Africa. Project Atlas, a database of WHO's Department of Mental Health and Substance Dependence, showed that 38% of 190 countries do not have a national mental health policy and within WHO regions, Africa and the Western Pacific show the lowest percentages.
India with a population of over a billion persons is yet to have a comprehensive mental health policy. It spends about 2% of the national budget on mental health. In the early 80s, the National Mental Health Programme envisaged the integration of mental health with primary care, but even after two decades, this has not been uniformly implemented. The recommendations of the National Human Rights Commission after a survey of the mental hospitals in the country and the tragedy in which over 25 chained mentally ill persons were charred to death were two events which have shaken up the system and led to some increments in budgetary allocation and better monitoring by health authorities.
Peru in south America does have a mental health policy and regular funds for its implementation but only 25 to 50% of its original content have been put into practice. Since Peru's initially policy formulation in 1991 many efforts have been made to enhance mental health interventions but with frequent ups and downs. Reasons suggested for theses problems have been the assumption of incomplete policies, professional issues, lack of social commitment by the persons in charge of the implementation, lack of coordination with other social sectors, etc.
The gap between need and service is big in most African countries, particularly those in the sub-Sahara region. Harnessing the available human and material resources to bridge this gap requires the development of practical policies and programmes and their focussed implementation. Unfortunately, many African countries have not risen to this reality. Many do not have policies and programmes for tackling mental health problems and, those with policies, do not implement them faithfully. Suggestions are made on the desirable elements of a mental health policy and on effective ways to ensure their implementation.
MENTAL HEALTH POLICIES IN PERU
Javier E. Saavedra
Project Atlas, a database of WHO's Department of Mental Health and Substance Dependence, shows that 38% of 190 countries do not have a national mental health policy and within WHO regions, Africa and the Western Pacific show the lowest percentages. Besides South-East Asia Region, the Americas and Africa show the least population coverage by a mental health policy, being around one third of the population. Peru does have a mental health policy and regular funds for its implementation but only 25 to 50% of its original content has been put into practice. Since Peru's initially policy formulation in 1991 many efforts have been made to enhance mental health interventions but with frequent ups and lows. Reasons suggested for these problems have been the assumption of incomplete policies, professional issues, lack of social commitment by the persons in charge of the implementation, lack of coordination with other social sectors, etc. In addition deficient information related to mental health problems hinders the development of adequate mental health policy planning. Since 2003, the Peruvian National Institute of Mental Health has reported the results of epidemiological studies conducted in different cities of Peru. Nevertheless, little of this work has been traduced into mental health policies which are the responsibility of the Ministry of Health. It is suggested that besides the confrontation of the aforementioned problems it is necessary to create an administrative level where identified problems could be disseminated and transformed into social projects or programs.
FO04 ROLE OF PSYCHIATRISTS AND MENTAL HEALTH PROFESSIONALS IN PROMOTING MENTAL HEALTH
Helen Herrman, Shekhar Saxena, Oye Gureje, Rachel Jenkins, Rob Moodie, Beverley Raphael
Improving mental health for a community requires population based measures to promote mental health as well as clinical services for people living with mental illnesses. Neither can be fully successful without the other. They require separate financing and methods. We can take the example of heart health, where population-based measures to encourage change in diet and exercise habits have made indispensable contributions over 30 years to containing the epidemic of heart disease and improving physical fitness in many countries.
Clinicians and mental health experts have important roles in advocating to governments and policymakers to support public health measures. The first speaker will describe the work of the WHO in promoting mental health in countries that are poorly resourced as well as wealthier countries with a stronger record of activity in this field. The next speakers will comment on the role of professionals in a variety of settings. The discussants will encourage audience participation by commenting on the presentations and are likely to note the need to build bridges across professional and sectoral interests.
MENTAL HEALTH PROMOTION BY MENTAL HEALTH PROFESSIONALS: PRACTISING WHAT WE PREACH!
Shekhar Saxena
On an average, mental health professionals spend a very small proportion of their professional time on promotion of mental health and prevention of mental disorders. This is especially true for psychiatrists. The possible reasons for this may include inadequate awareness of evidence for effectiveness of these interventions as well as lack of skills and confidence in implementing them. Heavy demand and substantial pressures for treatment and care are also likely reasons. Lastly, the current financing mechanisms are also not conducive for promotion and prevention work.
WHO's recent work in the area of promotion and prevention will be briefly described. This includes reviews of evidence and case studies from across the world. Presently, WHO is developing a guidance package to provide clear and simple advice on the practice of mental health promotion by specific target groups, including mental health professionals. The guidance package will be disseminated widely specially in low and middle income countries. It is expected that this material will strengthen the capacity of mental health professionals in implementing mental health promotion in their own work as well as in their collaborative work with other professionals within the health sectors and outside.
CHALLENGES OF MENTAL HEALTH PROMOTION IN LOW- AND MIDDLE-INCOME COUNTRIES
Oye Gureje
Mental health promotion is particularly needed in developing countries where mental health awareness is low and preventable causes of mental illness are common. In such settings, mental health promotion programmes can draw on mental health enhancing traditional social values which are still relatively common. However, mental health service delivery faces a number of difficulties in low- and middle-income countries: poor attention from policy makers, under-resourced system, and paucity of manpower. In such settings, mental health professionals are stretched providing service for those with mental disorders and hardly have time for mental health promotion. This presentation will offer suggestions on how mental health promotion can be implemented within the constraints of resources that exist in low- and middle-income countries.
ROLES OF PROFESSIONALS IN PROMOTING MENTAL HEALTH
Rachel Jenkins
Mental health professionals have crucial roles in promotion of mental health, which range from valuing and advocating for positive mental health for all, developing an evidence based understanding of what types of intervention work best in various settings, developing shared conceptual understanding with front line professionals in key sectors such as teachers, police, prison officers, social workers, and playing key roles in building the infrastructure for mental health promotion. Such infrastructure requires a strong policy context, intersectoral approaches, developing effective practice, investment in research, facilitating partnerships and collaboration, and strengthening the links between research, policy and practice. For mental health professionals working with adults, a particular focus is likely to be the promotion of mental health in the workplace, and the promotion of reemployment of people who lost their jobs through illness. For mental health professionals working with children and young people, a particular focus will be on promotion of mental health in schools, colleges and universities to promote academic, social and emotional competence and significantly reduce school drop out rates and a range of negative health and social outcomes.
FO05 ELEPHANT IN THE ROOM: RACISM AND INDIGENOUS MENTAL HEALTH
Joanne Baxter; Yin Paradies; Ricci Harris, Ann Larson, Marisa Gilles, Peter Howard, Juli Coffin, Ian Anderson
A brief summary of the symposium Racism and Indigenous health: setting the research agenda in Australia and New Zealand held prior to the WPA International Conference will also be provided.
Yin Paradies
Ricci Harris
Ann Larson, Marisa Gilles, Peter Howard, Juli Coffin
Research has demonstrated the association between the experience of racist behaviour and poor mental health for members of racial and ethnic groups in the United States, United Kingdom and New Zealand. Similar work on the consequences of racist behaviour for Indigenous Australians is limited. Here we will report on the results of a population survey conducted in a remote centre. A sample of 183 Indigenous residents answered questions about their experience of recent negative racially-based treatment, their civic engagement, trust in services and other population groups, and self-reported health indicators. Recent negative experience was significantly associated with poor mental health status. It was also strongly related to lack of confidence in civic leadership, lower levels of social interaction outside of one's immediate family and lower levels of trust. The effects of racist behaviour are far reaching, excluding the Aboriginal people who experience it from full participation in society and leaving them vulnerable to poor mental health.
Ian Anderson
This short paper will summarise the symposium Racism and Indigenous health: setting the research agenda in Australia and New Zealand held on the 27th November 2007.
FO06 GLOBAL PERSPECTIVE ON SIGNIFICANT ISSUES IMPACTING ON WOMEN's MENTAL HEALTH
Jayashri Kulkarni, Beverley Raphael, Vikram Patel, Kelsey Hegarty, Fiona Judd
Why consider women's mental health issues separately from men's mental health issues? There are many important and unique issues that impact adversely on women's mental health which will be highlighted in this forum. Medicine still generally assumes that the archetypal patient and physician are men. Yet women constitute the greatest percentage of the population receiving treatments for mental illness in most societies. In a global sense, poor socioeconomic status, a perceived inferior position in some respects and greater dependency on others for her existence may contribute to the development of mental illness in women. Violence against women is a significant contributor to the development of mental illness and will be examined in Eastern and Western cultures in this Forum. Certain psychiatric illnesses are only seen in women such as post partum disorders, menopause – related changes in mood and the associated mental health aspects of specific female reproductive system cancers. The biological, psychological and social issues associated with theses disorders will be explored.
WOMEN AND CATASTROPHES
Beverley Raphael
MENTAL HEALTH ASPECTS OF VIOLENCE AGAINST WOMEN IN DEVELOPING COUNTRIES
Vikram Patel
MENTAL HEALTH CONSEQUENCES OF INTIMATE PARTNER ABUSE IN AUSTRALIA
Kelsey Hegarty
MENTAL HEALTH ASPECTS OF CANCER IN WOMEN
Fiona Judd
HORMONAL IMPACTS ON MENTAL HEALTH OF WOMEN
Jayashri Kulkarni
FO07 VIOLENCE, TRAUMA AND DEPRIVATION – MENTAL HEALTH CONSEQUENCES FOR CHILDREN AND THEIR COMMUNITIES
Sam Tyano, Sandra Radovini, Miri Keren, Louise Newman, Lakshmi Vijayakumar
‘The world is a dangerous place!’ a cliché but nevertheless a reality for millions of children around the globe from the most affluent societies to the most impoverished. What is the cost of exposing to or being unable to protect children from violence, trauma and deprivation be it familial, societal or systemic abuse or ‘natural’ disaster? What role do psychiatrists and mental health clinicians have in not only providing assistance but advocating on behalf of this most vulnerable and helpless group in our communities? What is the impact on health care provision and resources? In the often ensuing chaos, distress and despair what are the short and long term consequences on the early developmental stages of life?
This forum will explore some examples from around the world:
The impact of childhood abuse Child asylum seekers and mandatory detention ‘Life after the Tsunami’
FO08 COMMUNITY MENTAL HEALTH: IMPLEMENTATION AND PRACTICE
Shekhar Saxena, Chee Ng, Chris Underhill, Yvonne D.B. Bonner, Margaret Leggatt
The World Health Organization (WHO) signalled the urgent need for countries to provide a network of community mental health services at its Global Forum for Community Mental Health this year. Community mental health services provide better care, ensure earlier intervention, help preserve the dignity of mental illness sufferers, and limit the stigma of mental health treatment. The call for community mental health services is especially timely since, as indicated by the Mental Health Atlas (2005) report, only a few countries have made adequate progress in this area. Also, in many countries, closing of mental hospitals is not accompanied by the development of community services. The forum will explore the need to establish clear policies articulating these measures, the approaches to implement these effective services systems, and how strategies can be applied in practice.
COMMUNITY MENTAL HEALTH SERVICES: THE GAP BETWEEN WHAT WE SAY AND WHAT WE DO
Shekhar Saxena
Community mental health has been recommended as the most appropriate and effective strategy for treatment and care of persons with mental disorders. In principle, this strategy is accepted by all stakeholders, including those leading the public health care systems. However, WHO data suggest that the resources devoted to community mental health services are still a small proportion of the overall resources for mental health in most countries. This proportion is especially low in low and middle income countries, where the overall health and mental health resources are also scarce. Data from WHO's Mental Health Atlas and from WHO's Assessment Instrument for Mental Health Systems (WHO-AIMS) study will be presented to demonstrate the poverty of resources for community mental health globally and within regions of the world. Barriers against enhancement of these services and strategies for overcoming these will be discussed.
PUTTING COMMUNITY MENTAL HEALTH AND DEVELOPMENT INTO PRACTICE
Chris Underhill
Since 2000 the Model for Mental Health and Development has been field tested in seven developing countries in both Africa and S.E. Asia by the organisation BasicNeeds an international NGO registered in the UK. The model is derived of five modules: 1) capacity building, 2) community mental health, 3) livelihoods, 4) research and 5) administration. This is an economic and social model of development in which treatment needs and income requirements are both met mostly through the development of self help groups of mentally ill people and their primary carers. Since inception 41,251 mentally ill participants and 37,000 primary carers (December 2006) have taken part in the programme.
BUILDING PARTNERSHIPS FOR A COMMUNITY MENTAL HEALTH SYSTEM: ENSURING SUPPORT TO PARTNERS
Yvonne D.B. Bonner
The basic question is: “who ensures support to whom? And what for?”.
A look into the history of psychiatry – and specifically into the history of community mental health – reveals that the first step towards the organization of a community mental health system is to close mental hospitals, the second to develop community mental health services and the third to deal with the mental health question as an overall cultural field of investigation.
Discourses and general strategies concerning community mental health (CMH) are not sufficient, it is imperative to act at grass-root levels in order to focus on the “best practices” in CMH partnerships that are already effective.
Partnership building is a demanding task that comprises users and mental health personnel, but also includes schools, families, social services, voluntary local organisations, etc.
Moreover partnerships produce a terrain that upholds the co-construction of a novel understanding of mental health and mental ill-health. Within this context – of partnerships and alliances – people learn to cope with differences in opinions and experiences. They get to acknowledge the complexity of the field and discover the strengths of a care system based on differences.
Networks and partnerships can survive if flexible, questioning, open and supportive. Power-relationships in these circumstances obviously alter and hence generate fresh ideas and uncommon approaches to CMH such as active collaboration offered by users and families providing expertise in many sectors including crisis intervention, training of health personnel and academic research.