Course

We have provided a range of resources in this course that will assist you as a health and social care practitioner in promoting community mental health resilience within specific communities. You can work through the activities at your own pace and participate as appropriate as you navigate your way through the course. 

Learning Journal

Keeping a learning journal is an important first step to take when completing the course as it enables you to write and create diagrams about what you are learning as you engage in the various course activities. Some entries may be short and specific whereas others reflect on what you have read or learned. Noting your reflections can deepen your learning experience. You can use a notebook or create a word document to record your learning on the computer or other digital devices. The key is to make it a fun and interesting experience rather than a chore.

(Photo created by freepik - www.freepik.com)

There are other interesting exercises that will stimulate your learning such as the facilitative activities and quizzes. Do engage with them and make your learning fun and interesting rather than a chore.  

Good luck with the course!

Mental health

The term mental health is often used interchangeably with mental illness. In a positive sense it is the foundation for well-being and how individuals function within their community. The World Health Organisation defines mental health as “a state of well-being in which an individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively, and is able to make a contribution to his or her community.” In contrast, mental ill health is associated with abnormal psychological and emotional experiences and behaviour that are not recognised as being part of normal individual development or the cultural norms of a given society.  It can affect the individual’s relationships, their work and their quality of life.

Reflection (5 minutes)

Spend a few minutes thinking about mental health and write down what you think it is.

Comment 

Did you find this difficult? Words that often appear are, cheerful, thoughtful, happy. Remember that in some circumstances you may not always feel so positive. Mental health can vary depending on the individual’s emotional state especially if coping with uncertainty and feeling unconfident due to specific stresses within a household or job. In such circumstances the individual’s coping ability may diminish. What’s really important is understanding how someone’s emotional state can impact on them when faced with circumstances they find stressful.

Mental ill health

A number of terms are used to describe mental ill health including:

• Mental disorder
  
• Mental health problems
• Mental distress
• Mental illness

There is still a great deal of controversy about what is ‘mental ill health, what causes it and how individuals can be helped to recover from the conditions. In this course we look at building resilience in a community to strengthen more specific interventions. This section provides an insight into the types of disorders that you are likely to come across.

Mental ill health is usually divided into a range of common disorders/illnesses. These include:

Other mental health related issues you may notice include self-harming behaviour. Self – harming is not a mental illness, but it is often linked to mental distress.  Self-harm is harming yourself on purpose such as scratching, cutting, overdosing on medication, biting or burning. An individual may self-harm because they find it difficult to cope with particular traumatic situations rather than suffering from a specific mental health issue.

Individuals with mental ill health often experience and display a range of signs and symptoms not present in those who are mentally healthy. The various disorders listed below gives you an indication of the types of signs and symptoms an individual may exhibit.    

Anxiety disorders – conditions that cause an individual to be afraid or anxious most of the time or in specific circumstances. This source of anxiety may be unspecified or based on a particular phobia e.g fear of other people (social phobia).

Mood disorders – conditions that depress the mood and produce episodes of elation or mania. Bipolar disorder combines both depression and mania. Depression is the most common mood disorder and signs and symptoms include sadness, loss of interest in life, sleep disturbance, tearfulness and changes to appetite. 

Psychotic disorders – serious conditions where the individual loses contact with reality periodically or permanently. These are characterised by hallucinations – hearing voices or seeing things that are not there, delusions which are false fixed beliefs held by the individual that believe it is true despite the evidence and thought disorders – rambling and incoherent speech patterning, individual’s thinking is blocked or repeated. Schizophrenia is one of the most common disorders.

Eating disorders – most common are anorexia nervosa and bulimia. Those with anorexia are inclined to over exercise, under-eat and will make themselves sick to control their weight. Individuals with bulimia nervosa over-eat by bingeing on food and then vomit as a way of restricting their calorie intake.

Obsessive compulsive disorders – individuals have constant thoughts or fears that cause them to perform certain rituals or routines. The disturbing thoughts are called obsessions, and the rituals are called compulsions. An example is an individual with an unreasonable fear of germs who constantly washes their hands.

Cognitive disorders – conditions that affect the individual to think or use their memory. Most common is dementia especially Alzheimer’s disease.

Substance misuse – Individuals who develop a dependency on drugs, alcohol or other addictive substances. They exacerbate or make worse other mental ill health problems.

(Walsh et al 2011 p. 289)

Reflection (10 minutes)

Globally one billion people struggle with issues, including depression, substance abuse and self-harm (WHO 2018) and these are especially prevalent in lower income nations. Fragmented service delivery, lack of research and policy in mental health as well as barriers to people seeking help like stigma make tackling mental health in these nations challenging.

Guyana Context

In Guyana, mental health services are sporadic and barely functional in some communities. Stigma continues to exist around mental ill health and has hindered efforts to provide appropriate mental health services. Poor mental health can contribute to low productivity, weak civic society, high disease burdens and can lead to traumatic experiences for all. A proactive and novel approach was adopted by a research team that aimed to strengthen three communities’ resilience in order to promote better mental health and wellbeing, through identifying and sharing successful local practices that had evolved over time. The participants in this project demonstrated how they coped with challenging personal, cultural, organisational and environmental stressors and conditions which they would like to share with others in their respective communities and the wider Guyanese society. We believe there is a need to go beyond conventional approaches to mental health and focus on a model that promotes community resilience and wellbeing.

Culture and religious beliefs can influence how people think about mental health and illness. In the Guyanese culture some beliefs about mental illness are attributed to  witchcraft known locally as obeah which can impact on the person seeking help. Those who consult with religious leaders may find they misinterpret mental health symptoms on some occasions. Caution is required when seeking help and support for mental ill health.

Map of Guyana highlighting the location of the main ARCLIGHT communities in Georgetown, Enmore and Yupukari.

Activity (10 minutes)

Consider the “physical, social, economic, psychological and other” barriers to mental health support in low income nations and complete the columns by trying to think of additional barriers.

Reflection (10 minutes)

Now think about the way mental health is perceived in your country and the mental health support that is generally available. Does your perception match the statistics and status you obtained from the WHO overview?

Optional Reading (5 minutes)

Read the following blog by ARCLIGHT project manager Kerese Collins as an example for her reflections on mental health in Guyana.

http://www.open.ac.uk/blogs/ARCLIGHT/index.php/2019/07/05/reflections-on-mental-health-in-guyana/

Optional Activity (30 minutes)

Conduct brief (5-7 minute) interviews with 3 of your friends or family members about their perception of mental health challenges that Kerese mentioned in your country and globally. Reflect on your interviews and compare your notes with your previous reflections. Are there any additional challenges and barriers that you hadn't considered before? If so, add them to your table from the previous activity.

It is useful to use a tried and tested model when considering how an individual is influenced by the community or the environment he/she lives in. This will help to map out the influences and support available to community members. One useful model is Urie Bronfenbrenner’s social ecological systems theory (Bronfenbrenner 1979). This theory was originally developed to explain how a child’s development and growth is influenced by the many environmental factors which come to influence them. Bronfenbrenner’s ecological theoretical framework is now used more broadly by mental health practitioners as a tool to help understand the complexity of human behaviour and the environmental influences that impact upon a community or an individual. For instance it has been used in the mental health field to guide public health policy by helping to identify where change is needed.

The Bronfenbrenner theory emphasizes the importance of studying people in multiple
settings. Five important levels are identified by Bronfenbrenner and he suggests that if
positive changes or problems occur in any one of the levels, these will have an impact on the other levels. The five levels are: 

The ARCLIGHT approach gives practitioners the freedom to focus on the level that is most appropriate for the situation. It is likely that different situations may need a focus on a selection of some but not all of these levels, and practitioners need to be realistic about which level can have the greatest impact.

By intervening at these levels the aim is to identify strategies that have been developed for dealing with opportunities and challenges emerging from any of the five levels therefore promoting resilience.

Drawing (10 minutes)

Now draw out your own version of Bronfenbrenner's framework as a diagram and fill each circle with specific examples from your life. How does each of those levels look like for you?

It is important to clearly articulate what community members perceive to be the challenges in their own community. For example, the following is a summary of challenges of a typical community in Guyana. Many community members rely primarily on agriculture, fishing and/or hunting, but the challenges of disruptive and extreme climatic conditions, such as droughts and floods are beginning to affect their subsistence livelihoods. The community is faced with lack of employment opportunities as in some cases major employers have shut down factories (such as sugar estates) forcing many youths to leave for mining or poorly paid jobs in urban centres, if any paid jobs can be found at all. 

Malaria, dengue, water and air pollution, dysentery, alcoholism, domestic abuse, teenage pregnancies, unsustainable over-extraction of natural resources, wildfires, and a loss of traditional cultural practices and customs are all escalating problems. Services such as health clinics, transportation, schooling and policing are also in need of improvement. These difficult circumstances have meant that many community members feel helpless in facing up to these seemingly insurmountable problems.

It is important to re-emphasise here that the aim of the ARCLIGHT approach is to develop the community around what already works, rather than trying to fix what doesn’t. But any community-based mental health intervention needs to appreciate the challenges within which it is operating.

Drawing (10 minutes)

Re-draw the following diagram and fill in the diagram with examples of , economic/physical/infrastructure, social/cultural and environmental based problems or issues that can affect community resilience. Those can be general examples, examples that you have now learned of in the context of ARCLIGHT or examples specific to your community.

Review and Reflection (20 minutes)

Think about a possible mental health intervention in a community you know. This could be your own community, a community where you've worked before or might even already be planning to implement a community mental health intervention. Reflect on what you have just learned about applying Bronfenbrenner's framework and think about which level you would choose for an intervention in this community.

Optional Activity (45 minutes)

Organise a meeting with your community and introduce the ideas about community and mental health resilience you have learned. Reflect on the responses, do they match your perception?

Example of a community meeting in the North Rupununi.

Reflection (10 minutes)

Reflect on your community or the community you are working with. Who might suitable gatekeepers be? How would you approach them?

Optional Activity (20 minutes)

Keeping in mind what you have learned about free, prior and informed consent in this section - Think about your next upcoming project or reflect on a past project you did and create a step-by-step approach that you would follow for it now.

In order to promote community mental health resilience, the use of Participatory Action Research (PAR) techniques are recommended. PAR methodology is a social, practical and collaborative activity where the building of relationships among all participants and the research team are crucial as they work towards self-determination and reform. PAR is an appropriate approach as it allows participants to give voice to their experiences and deliver outcomes based on them being co-researchers rather than attempting to impose predetermined actions or activities.

PAR adopts the philosophy that “that people have a right to determine their own development and recognises the need for local people to participate meaningfully in the process of analysing their own solutions, over which they have (or share, as some would argue) power and control, in order to lead to sustainable development” (Attwood, 1997, p. 23). Our recommendation for starting off with a community is to first explore what is working well within a community and then use the PAR intervention to consolidate and build on existing mental health resilience building solutions. The aim being to develop the community around what already works, rather than trying to fix what doesn’t.

Participatory action research is done using iterative cycles using the phases of planning, action, observation and reflection. The outcomes from the reflection of each cycle inform the planning phase of the next cycle.

Reflection (10 minutes)

Think about what the key challenges might be when engaging in participatory action research, both in general and for yourself personally. Write your thoughts down in your learning journal.

Becoming a participatory action research facilitator

It is important to use facilitation skills when applying the PAR methodology to group activities to enable participants to reflect and consider several courses of action. Facilitated PAR sessions encourage collaboration among the researchers and participants and key aspects of facilitation skills can be used within a group setting.

Read the following list of facilitation skills and reflect on each of them. Do you know what is meant by this skill? Which of these skills do you already have? Can you recall examples from your own life of when you've successfully used those skills? Note down your reflections in your learning journal.

• Act as a catalyst to bring about change
  
• Negotiate with the group about the role of the facilitator
• Use active listening skills
• Stimulate people to change by addressing issues that concern them now
• Use participants own words to record and listen
• Seek clarification and check what has been said
• Respond through reflection
• Help participants to analyse their situation
• Enable people to consider several courses of action
• Stimulate rather than impose change
• Assist participants to analyse their present situation, consider what they find and then plan for what they would like to change

Activity (2 hours)

This activity encourages you to start using your facilitation skills. Read the information above on facilitation and the type of skills that you use to engage with your participants and identify a group of colleagues or friends, about 5 in total and ask each one to answer the following 5 questions in a small group setting. Start to encourage a discussion around their responses. 

• What music do you listen to? 
• Name a favourite tune.
• What is your favourite colour and why? 
• Think of something in your environment that describes you? 
• What are your hopes and aspirations for the future? 

As you engage with the group think of the facilitation skills you are using. Whilst this may be a fun activity, you are using listening, questioning skills, seeking clarification, and encouraging the individual to respond to your questions rather than engaging in any in depth analytical work. You are beginning to reflect on how you interact with others in a group setting which you can note down in your journal. 

Activity - Keeping a reflective diary (25 minutes)

Here are some prompts for how to write reflectively based on Borton’s (1970) reflective framework. Try to reflect on the previous activity where you focused on developing your facilitation skills using the following approach. 

What (Description): Identify an event and write a descriptive account about:

• What happened?
  
• Who was involved?

So what? (Interpretation): Spend some time to reflect on what is happening in the event.

• Consider what is the most important aspect of the event
  
• Were there any misunderstandings?
• If so clarify these and explain
• How is this event similar to or different from others you have experienced?

What’s next: Conclude what you have learned from the event and how you can apply it to future situations.

• Identify what you have learned
  
• Suggest how your learning can be applied in the future 

Participatory methods for creating digital stories

Now watch the following video and write down any additional elements about the benefits of using visual communications.

Optional Reading (5 minutes)

For additional inspiration, read this blog by Helena Ann Mitchell about her experiences with women who have encountered domestic violence and the stories of resilience emerging from their experiences.

http://www.open.ac.uk/blogs/ARCLIGHT/index.php/2020/07/10/reflections-of-my-experiences-with-women-who-have-encountered-domestic-violence/

Activity (20 minutes)

Here are some examples of questions that can be used to create positive stories of resilience:

• Can you recall a pleasant experience within your community and encourage participants to share these experiences with each other?
• How has the community coped with adversity?
• What do you think resilience/bouncing back from life’s hardships means?

Think about your community and see if you can come up with at least two different examples of such stories.

Drawing (20 minutes)

Using the feedback on your idea that you got in the previous activity, try to develop that story a little further. If you can, draw some images or create something else that illustrates the story to you. For inspiration and examples if you haven't read it already, read Helena Ann Mitchell's blog post featuring some of the drawings made my participants in the ARCLIGHT project. 

http://www.open.ac.uk/blogs/ARCLIGHT/index.php/2020/07/10/reflections-of-my-experiences-with-women-who-have-encountered-domestic-violence/

The digital storytelling approach championed by ARCLIGHT focused on creating narrated slideshows using mobile phones. This is one of the easiest ways that a digital story can be created. Participatory Video is one highly effective visual technique that can be used for such participatory visual storytelling.

Watch the following video for a brief introduction to this technique.

Activity - Creating your first story (25 minutes)

Read through the following table describing the steps of creating a digital story of community resilience. Afterwards, complete steps 1 (Identifying the story), 2 (Creating a narrative) and 3 (Develop a storyboard) for a story of community resilience from your community or the community you are working in.

Optional Activity (6 hours)

Try to actually produce a participatory video showing a story of community resilience from your community. Depending on your situation, either get together with your research participants or friends and follow all the steps to produce a participatory video. You can find more instructions and tips for creating participatory videos in the Cobra Collective Guide for finding and sharing community owned solutions (https://cobracollective.org/resources/).

Activity (30 minutes)

Share your idea for your story with at least 2 members of your community - how do they perceive this story? Observe their reaction and ask them how they feel about using this as an example of resilience. Write down your thoughts and reflections in your learning journal.

Reflection (15 minutes)

Reflect on your experience during the previous activity using the reflective prompts that were introduced in the section about "Participatory Action Research". How do you feel about the potential of your story to contribute to fostering community mental health resilience now?  

Optional Activity (10 minutes)

Watch this video presentation on "Building community mental health resilience through digital storytelling" and write down any new insights this gave you into the ARCLIGHT project.

Using DIY networks to record, share and debate digital stories

If you're new to the idea of local networks and MAZI, watch the following video to help you understand this concept.

Drawing (20 minutes)

Draw a diagram showing the process of sharing stories through local networks following the 5-step method and using your notes from the previous activity. In your diagram, show each of the 5 steps and for each step indicate which technical tools you would choose and how you will interact with the community.

Optional Activity (2-5 hours)

(This requires you have access to a Raspberry Pi 3, a spare SD card of 8Gb or more, and the ability to format the SD card)

Try to set-up your own MAZI Zone following the instructions of the toolkit on the MAZI website (http://mazizone.net/mazi-eu/toolkit_guidelines/). Try uploading and sharing information via the MAZI zone and practice instructing others to share and access information independently following the 5 step method.

Evaluation is understanding how far objectives are being achieved and how to measure results. This should be done from the beginning of an intervention. We call this “upstream evaluation”. First, you need to understand the initial situation: what people think, what challenges people are facing and what goals people have.

Throughout the intervention it is important to monitor progress, and use regular reflection and feedback to improve processes as you continue. Corrections can be made to improve the final results.

Towards the end it is important to understand what the results are: what has changed in the situation as a result of the work, and what might be tried next time.

Activity (30 minutes)

Think about your most recent community engagement or research project and answer the 6 P's introduced in the previous reading activity. If you haven't done such a project before, try to think of either your own community or a community you are likely to work with in the future and try to answer the 6 P's. Allow yourself to take the time to really think about and answer each of the P's in detail.

Drawing (15 minutes)

Consider how you would do an evaluation of a community intervention and draw your idea out as a diagram.

Activity (60 minutes)

Try to develop and carry out a practice baseline survey either about a concrete community intervention idea you will carry out or about an idea you have. Think about which questions might be useful to ask to help you evaluate the impact of your project later. How are you going to select the people you will interview? Note any concerns, challenges or insights you encounter while engaging with this activity in your learning journal.

Contributors

Helena Ann Mitchell, Julia Jung, Andrea Berardi, Mark Gaved, Kerese Collins, Tania Hart, Gareth Davies

References

Attwood H (1997) An overview of issues around the use of participatory approaches by post graduate students. Participatory Research, IDS PRA Topic Pack, IDS, Brighton: University of Sussex.

Borton T (1970) Reach, Touch and Teach. London: Hutchinson.

Bronfenbrenner U (1979) The Ecology of Human Development: Experiments by Nature and Design. Cambridge: Harvard University Press.

Walsh, M., Mitchell, A., Millar, E., Rowe, J., Greenhalgh, L., Langridge, E. and Chaloner R. (2011) Health and Social Care. Level 3 Diploma Handbook. London: Collins

World Health Organisation (2003) Investing in Mental Health. WHO, Geneva.

World Health Organisation (2018) mhGAP Operations Manual: WHO, Geneva.

Music in the introductory audio recording: "Shine Willows" by www.hooksounds.com