Building behavioral health systems from the ground up

Wahlbeck's paper (1) provides a succinct and accurate overview of the public health approach to global mental health. Conceptually, public health incorporates not just evidence-based interventions from high-income countries, but also significant emphases on positive behavioral health, prevention, recovery, and social, cultural and environmental factors.

Expanding global mental health to include positive behavioral health – and therefore all people – offers the advantage of attention to developmental needs, resilience, prevention, and recovery (2). The behavioral health field has ignored these issues and the related empirical research findings for too long. Relatedly, shifting from “mental health” to “behavioral health” could underscore the broad focus on healthy behaviors rather than a narrower focus on mental illness. As one ramification, mainstreaming behavioral health to the entire population may reduce stigma for those who experience the most severe disabilities.

The practical implementations of the Movement for Global Mental Health have been criticized extensively (3). Despite its holistic and laudable rhetoric, implementation attempts have largely involved an expansion of Western evidence-based biomedical or psychological interventions delivered via lay health workers and have not been sensitive to cultures and communities. Local communities often object to the imposition of Western models of individual mental illness when the problems are widespread, the culture is not so individualistic, and behaviors are obviously related to war, poverty, gender discrimination, lack of opportunity, and so on. The failure to engage communities and understand cultural values and norms has sometimes worsened rather than relieved widespread community distress (4).

The use of lay health workers helps to expand services and engender trust (5), but these workers typically make diagnoses and dispense medications or psychological therapies following a Western medical model. How could community engagement efforts align more closely with local culture? One basic strategy could be to start with local people on the ground. “Top-down” solutions (i.e., those developed by government experts) that are imposed on communities are often bureaucratic, reductionistic, overly prescriptive, and insensitive to local culture and context. The expensive and inefficient Veterans Administration Healthcare system in the U.S. is often cited as an example of the failure of top-down systems (6).

By contrast, “ground-up” approaches (i.e., those developed by local stakeholders and communities) may better serve the goals of public mental health by valorizing local knowledge, competence, and resources. People on the ground – those experiencing behavioral health problems, their families, and their communities, aligned with local leaders, professionals, healers, and health workers – may in fact be in a better position to recognize local needs and resources, to understand local culture, to select and adapt appropriate evidence-based practices, and to innovate solutions. Local culture, however, may sometimes perpetuate stigma and even violations of human rights – hence the need for collaborations with professionals via mutual learning. Learning communities (multi-disciplinary groups focused on a specific health issue) have successfully combined local stakeholders with outside experts to discuss, select, and evaluate potential solutions (7).

Community engagement could be enhanced on a global basis via several strategies. First, governments should give priority and funding to ground-up approaches. Community engagement in health care has a long and rich tradition, including principles and strategies for identifying and solving problems (8). Local community activation has in fact often produced positive changes and sometimes led to national and international health reforms: witness the women's health movement in the 1960s and the AIDS movement in the 1990s in the U.S..

Second, the field should recognize that people with behavioral health syndromes generally have goals that differ from those of professionals (9). Rather than more and more medications to reduce symptoms, people generally want support in finding meaningful functional roles. If local people (rather than industry, government, and the medical profession) were to choose services and goals, behavioral health would shift dramatically. For example, women who are oppressed and abused would be likely to emphasize education, advocacy, legal action, employment, and financial independence rather than poly-pharmacy.

Third, healthcare systems should encourage people to develop natural resources, e.g., clubs, peer-support groups, spirituality, yoga, and other mindfulness-based therapies (10). These interventions, delivered by lay community members, are widely available in culturally specific forms and languages and can enhance prevention, resilience, treatment, and recovery. Government should encourage and strengthen these natural supports in local communities before assuming that more hospitals, professionals, and medications are the answer.

Fourth, lay health care workers should be given the opportunity to collaborate with the people in their communities in selecting the medical and psychosocial interventions that they want and obtaining the training that they need to be effective (11). Likewise, they should be given the choice to veto or adapt interventions that are perceived as harmful or culturally insensitive. Such an approach may require extensive discussions within communities and suspension of Western hegemonic beliefs about the immutability of science-based interventions.

Fifth, behavioral health technologies should be used to enhance all of these efforts in ways that maximize choice and cultural tailoring. A wide variety of web-based and mobile health applications are demonstrating effectiveness for prevention, empowerment, resilience, treatment, and maintenance (12). Low-income and middle-income countries are rapidly developing the connectivity that could facilitate widespread distribution, perhaps through lay health workers. Expanding and using these resources could helpfully overcome what is often perceived as the lack of a professional workforce while simultaneously empowering local communities.

Global attention to positive behavioral health for all people is essential. We would not gainsay efforts to increase access to evidence-based interventions, but current efforts should include a meaningful understanding and respect for local cultures, communities, and resources.