“Mind is the thing that we are dealing with when we are dealing with psychiatric challenges,” Ken Thompson says. “Mind is the thing in us that allows us to be both in the world and inside ourselves at the same time.”
No matter which way you look at it, mental health is messy. Even as common knowledge of mind-related matters grows deeper and more nuanced, the issues at its core remain as mystifying as ever.
For all its complexity, one thing about mental health seems fairly certain. Our perception of it, and how we engage with it as a science, a system, and a social issue, will only continue to change. Here to help us make sense of it all are Ken Thompson, clinical associate professor of psychology at the University of Pittsburgh and National Advisory Council member at the Hogg Foundation, and Sheila Savannah, director of the Prevention Institute in Oakland, California.
Upward, Inward, and Forward: Renegotiating the Scope of Mental Health Care
According to Thompson, the evolution of mental health in the Western world breaks down into three loosely defined eras.
The first, which predates the scientific revolution of the 17th and 18th centuries, is a conception of psychiatric challenges that attributes them to spiritual maladies. Diagnoses of demonic possession, moral corruption, and witchcraft befell individuals with mental illness, who endured centuries of alienation and maltreatment as a result.
The rise of rationalistic thinking would eventually lead Western societies to an alternative approach to mental health treatment: institutionalization. In the United States, the task of establishing and maintaining state hospitals initially fell to state authorities. But by the mid-1950s, overstretched budgets severely limited the reach of state-sponsored welfare programs, leaving many hospitals overcrowded and underfunded.
“People began to think that not only are these institutions bad, and not good places to live,” Thompson says, “but that they were actually creating the psychiatric conditions they were supposed to treat.”
With the next decade came a tide of social welfare reforms that, via Medicaid and supplemental security income (SSI), redistributed the burden of care between federal, state, and local structures. In the mental health arena, the center of gravity shifted away from the institution to the community, depopulating hospitals and reinvigorating efforts to treat and understand mental illness.
Community-based models of care sought to undo the dehumanizing aspects of a strictly institutional approach to mental health care. In the ideal community, the material resources and social supports provided to patients at state hospitals are not just readily available, but interwoven into the fabric of daily life. What makes this possible is the engagement and participation of a collective that extends beyond those living with mental illness and their immediate circle of care — to the benefit of each and every individual involved.
“There are many ways that people become casualties of the context in which they live,” Thompson says. “In a context that is vibrant, healthy, interactive, engaging, sharing, diverse, cooperative – you’re going to have people who do and feel better, and have the capacity to be at their best.”
Thompson suggests that asset-based community development can be a means of creating such a context. The strategy first identifies people and resources (i.e. assets) within a community that are flourishing, then facilitates growth that purposefully expands upon their capacity for maximum functionality and wellbeing.
The ecological scope of community-based care has the potential to reconfigure power dynamics that, for centuries, have beset interactions between the producers and consumers of mental health services. “Ultimately, you can’t solve other people’s problems for them without them,” Thompson says.
Walking the Walk and Talking the Talk: Becoming Fluent in Mental Health
As mental health paradigms evolve, so, too, does the language used to describe them. But the rate at which jargon circulates and settles into ongoing discourse — as well as the jargon itself — changes from sector to sector and even group to group.
If organizations want to start conversations about mental health that don’t get bogged down in jargon, thoughtful translation is often needed. Sheila Savannah, who spent twenty years at nonprofits and nine more at the Houston Health Department before ending up at the Prevention Institute, explains that agreeing on operative terms at the outset of a project can make all the difference in expediting its outcome.
“We always ask people more deeply, ‘What do you use to define community?’,” Savannah says. “And that’s especially important when you’re working with community residents and community-based organizations – to really slow down and find out what definitions work for them.”
The buzzwords community health and population health have taken on many meanings since their coinage. According to Savannah, community health refers to a group of individuals united by some common interest or trait, whether it be a risk factor, diagnosis, or geographic border. Population health, on the other hand, can apply to groups that aren’t unified in any particular way.
In Savannah’s line of work, that simple distinction can do wonders in helping strategists sift through the many demographic and contextual layers that constitute community life. It also makes it easier for them to recognize the health inequities that lie beneath the surface — largely unnoticed, but deeply consequential.
“When I think about health equity, I think about the decisions and the investments in communities that really lead to walkability, that lead to safety,” Savannah says. Greenspace, public transportation, and even grocery store options are just a few features of the built environment that shape an individual’s mobility and security, and thereby their mental state.
In order to ensure that prevention measures can truly take root and mature in a community or population, leaders must keep an eye to the big picture and place great emphasis on coordination.
“We can make better traction in mental health philanthropy when we’re willing to accept the fact that our evaluations, too, have to be complex,” Sheila Savannah says. “They have to be contextual. They have to be layered, just like life in communities is layered.”
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