The paper by Tol et al. (Reference Tol, Purgato, Bass, Galapatti and Eaton2015) proposes a public mental health (PMH) approach to ‘humanitarian settings’, with specific reference to ‘mental health and psychosocial support’ (MHPSS). Such settings would generally include those impacted by disasters and armed conflict. PMH incorporates population-based approaches that not only address the occurrence of mental disorders but also implements strategies, based on evidence, to enhance and promote mental health and wellbeing (Wahlbeck, Reference Wahlbeck2015). War, persecution and torture have been noted – amongst other factors – as contributors to ‘poor mental health’ (Priebe, Reference Priebe2015) with such instances falling within the ambit of ‘humanitarian settings’ as described in the paper by Tol et al. (Reference Tol, Purgato, Bass, Galapatti and Eaton2015).
The implicit assumption is that a PMH approach would be superior to current approaches – which have been noted to be fragmented and not cohesive. In response to this fragmentation, guidelines for humanitarian support were developed in 2007 with the development of such guidelines involving 27 humanitarian agencies (Inter-agency Standing Committee, 2007). Inherent to the understanding of social determinants of mental health, in order to improve PMH, is the political role that psychiatry needs to play in order to translate evidence into policy, i.e. by linking with other fields to potentially ‘strengthen the political voice from mental health’. This is congruent with overcoming fragmented approaches to improve patient care (Priebe, Reference Priebe2015) which has direct relevance for the paper by Tol et al. (Reference Tol, Purgato, Bass, Galapatti and Eaton2015) that proposes utilising a PMH approach to humanitarian situations, specifically to address fragmentation of interventions in such situations.
Noting the aforementioned guidelines (Inter-agency Standing Committee, 2007), of specific importance was that they defined MHPSS. The definition comprised elements of PMH in specifying that the aims were to promote mental health (‘psychosocial wellbeing’) as well as prevent and treat mental disorders. Hence, by virtue of such aims the guidelines espoused a PMH approach without necessarily formally noting such an approach. Notwithstanding progress in this regard, Tol et al. (Reference Tol, Purgato, Bass, Galapatti and Eaton2015) highlight the ongoing ‘conceptual fuzziness and unresolved tensions’ and the absence of an overarching framework that allows for convergence and synergy – such a framework is proposed to be one provided by PMH. One might argue that such an approach runs the risk of imposing ideology. Whilst able to offer integration of inputs through a change in conceptual understanding, there is a need to address the issues of working collaboratively in a non-hierarchical way but with selective emphasis from individual role players based on need. In some ways, this mirrors the common clinical experience of managing a patient within a multidisciplinary team whereby each member has discrete functions with specific skill sets and a clear understanding of respective roles – but without the necessary coordination and leadership, efforts may not achieve the desired outcome. With respect to leadership, the issue of who takes overall control for coordinating, integrating and ultimately delivering is not addressed in the current paper.
A major obstacle will be how to influence existing role players, and in attempting to do so provide them with information that allows conceptual understanding and encourages uptake. Positions and approaches are historical and entrenched. Individual institutions have individual cultures. They may be resistant to change. Logic alone does not necessarily facilitate change. This is an important consideration, i.e. readiness and preparedness to accept and implement change. Tol et al. (Reference Tol, Purgato, Bass, Galapatti and Eaton2015) appear to be mindful of the pitfalls of shifting established approaches towards something novel, albeit well established within a different context, i.e. health promotion within the general population to limit disease and optimise wellbeing, productivity and quality of life.
Whilst the paper advances a theoretical basis for why a PMH approach may be an option to be considered, there is no direct evidence provided to support such a position. In this respect, one might argue that this is a highly speculative proposal, possibly even presumptuous given the lack of data to support. It should be noted that a recent paper by de Jong et al. (Reference de Jong, Berckmoes, Kohrt, Song, Tol and Reis2015) advocated a public health approach to the mental health burden arising from political violence and humanitarian emergencies – on a theoretical basis – for children and adolescents – proposing a range of strategies.
Limitations aside, there is much to recommend the position taken by the authors. In this respect, the current paper essentially sets out the basis for considering such change. More specifically, in advancing several reasons, the authors note that increased attention to a PMH approach ‘allows an examination of the relevance of a large body of prevention science for use with populations affected by humanitarian crises’. The word ‘relevance’ is critical. In certain examples, cited within the paper one might question whether methods of violence prevention in neighbourhoods with high levels of violence in cities in the USA could (rather than ‘may’) inform designs of interventions to prevent renewed violence in post conflict settings – where such conflict might have arisen within the context of political upheaval or ethnic/religious tensions. Are such situations actually comparable, albeit that violence is a common denominator? Is violence associated with crime comparable to violence associated with ethnic conflict? Is violence associated with urban crime in a city in the USA of any relevance to ethnic conflict in a rural setting in Africa? Context matters in terms of the basis for the development of a given situation which might require unique responses. However, this should not discount the possibility of an alternative, conceptually overarching framework that integrates and moves away from what might be regarded as a silo approach that is seen to characterise current approaches in humanitarian settings.
You have
Access
The paper by Tol et al. (Reference Tol, Purgato, Bass, Galapatti and Eaton2015) proposes a public mental health (PMH) approach to ‘humanitarian settings’, with specific reference to ‘mental health and psychosocial support’ (MHPSS). Such settings would generally include those impacted by disasters and armed conflict. PMH incorporates population-based approaches that not only address the occurrence of mental disorders but also implements strategies, based on evidence, to enhance and promote mental health and wellbeing (Wahlbeck, Reference Wahlbeck2015). War, persecution and torture have been noted – amongst other factors – as contributors to ‘poor mental health’ (Priebe, Reference Priebe2015) with such instances falling within the ambit of ‘humanitarian settings’ as described in the paper by Tol et al. (Reference Tol, Purgato, Bass, Galapatti and Eaton2015).
The implicit assumption is that a PMH approach would be superior to current approaches – which have been noted to be fragmented and not cohesive. In response to this fragmentation, guidelines for humanitarian support were developed in 2007 with the development of such guidelines involving 27 humanitarian agencies (Inter-agency Standing Committee, 2007). Inherent to the understanding of social determinants of mental health, in order to improve PMH, is the political role that psychiatry needs to play in order to translate evidence into policy, i.e. by linking with other fields to potentially ‘strengthen the political voice from mental health’. This is congruent with overcoming fragmented approaches to improve patient care (Priebe, Reference Priebe2015) which has direct relevance for the paper by Tol et al. (Reference Tol, Purgato, Bass, Galapatti and Eaton2015) that proposes utilising a PMH approach to humanitarian situations, specifically to address fragmentation of interventions in such situations.
Noting the aforementioned guidelines (Inter-agency Standing Committee, 2007), of specific importance was that they defined MHPSS. The definition comprised elements of PMH in specifying that the aims were to promote mental health (‘psychosocial wellbeing’) as well as prevent and treat mental disorders. Hence, by virtue of such aims the guidelines espoused a PMH approach without necessarily formally noting such an approach. Notwithstanding progress in this regard, Tol et al. (Reference Tol, Purgato, Bass, Galapatti and Eaton2015) highlight the ongoing ‘conceptual fuzziness and unresolved tensions’ and the absence of an overarching framework that allows for convergence and synergy – such a framework is proposed to be one provided by PMH. One might argue that such an approach runs the risk of imposing ideology. Whilst able to offer integration of inputs through a change in conceptual understanding, there is a need to address the issues of working collaboratively in a non-hierarchical way but with selective emphasis from individual role players based on need. In some ways, this mirrors the common clinical experience of managing a patient within a multidisciplinary team whereby each member has discrete functions with specific skill sets and a clear understanding of respective roles – but without the necessary coordination and leadership, efforts may not achieve the desired outcome. With respect to leadership, the issue of who takes overall control for coordinating, integrating and ultimately delivering is not addressed in the current paper.
A major obstacle will be how to influence existing role players, and in attempting to do so provide them with information that allows conceptual understanding and encourages uptake. Positions and approaches are historical and entrenched. Individual institutions have individual cultures. They may be resistant to change. Logic alone does not necessarily facilitate change. This is an important consideration, i.e. readiness and preparedness to accept and implement change. Tol et al. (Reference Tol, Purgato, Bass, Galapatti and Eaton2015) appear to be mindful of the pitfalls of shifting established approaches towards something novel, albeit well established within a different context, i.e. health promotion within the general population to limit disease and optimise wellbeing, productivity and quality of life.
Whilst the paper advances a theoretical basis for why a PMH approach may be an option to be considered, there is no direct evidence provided to support such a position. In this respect, one might argue that this is a highly speculative proposal, possibly even presumptuous given the lack of data to support. It should be noted that a recent paper by de Jong et al. (Reference de Jong, Berckmoes, Kohrt, Song, Tol and Reis2015) advocated a public health approach to the mental health burden arising from political violence and humanitarian emergencies – on a theoretical basis – for children and adolescents – proposing a range of strategies.
Limitations aside, there is much to recommend the position taken by the authors. In this respect, the current paper essentially sets out the basis for considering such change. More specifically, in advancing several reasons, the authors note that increased attention to a PMH approach ‘allows an examination of the relevance of a large body of prevention science for use with populations affected by humanitarian crises’. The word ‘relevance’ is critical. In certain examples, cited within the paper one might question whether methods of violence prevention in neighbourhoods with high levels of violence in cities in the USA could (rather than ‘may’) inform designs of interventions to prevent renewed violence in post conflict settings – where such conflict might have arisen within the context of political upheaval or ethnic/religious tensions. Are such situations actually comparable, albeit that violence is a common denominator? Is violence associated with crime comparable to violence associated with ethnic conflict? Is violence associated with urban crime in a city in the USA of any relevance to ethnic conflict in a rural setting in Africa? Context matters in terms of the basis for the development of a given situation which might require unique responses. However, this should not discount the possibility of an alternative, conceptually overarching framework that integrates and moves away from what might be regarded as a silo approach that is seen to characterise current approaches in humanitarian settings.