The Mental Health Facilitator Program:
Optimizing Global Emotional Health One Country at a Time
J. Scott Hinkle, Ph.D., NCC
Developing and promoting mental health services at the grassroots level, while at the same time maintaining a global perspective, is obviously an overwhelming task. However, NBCC’s International (NBCC-I) division has responded by collaborating with the World Health Organization’s Department of Mental Health and Substance Dependence to develop the Mental Health Facilitator (MHF) program. The MHF program addresses the international need for community-based mental health training that can be adapted to reflect the social, cultural, economic, and political realities of any nation or region.
Unfortunately, the lack of service providers who have the necessary competencies to address community needs is the most significant barrier to global mental health services. WHO’s Mental Health Atlas (2005) identifies a critical global shortage in mental health professionals (e.g., psychiatrists, psychiatric nurses, psychologists, social workers, neurologists). Similarly, an international survey of counselors by NBCC-I indicates that the professional counselor workforce has yet to be adequately identified on a global level. Existent mental health resources are inequitably distributed, with low income countries having significantly fewer mental health human resources than high income countries. The need to proactively address this care-need gap, from a praxis approach rather than a theoretical approach, has been identified by WHO and various national and international organizations, including NBCC-I.
NBCC-I has assumed the leading role for the ongoing development, standardization and maintenance of the MHF program, drawing on a variety of competencies derived from related disciplines, including but not limited to psychiatry, psychology, social work, psychiatric nursing, and counseling. An eclectic group of professional contributors allowed for a flexible training model with expertise drawn from various international practices. The MHF training curriculum was conceived as a dynamic document that is revised at regular intervals based on input from institutions and individuals who provide global MHF training.
The MHF program is designed to be implemented globally with an emphasis on the local community. The program consists of integrated mental health knowledge ranging from mental health advocacy and promotion to specified interventions such as suicide. The program is designed to be flexible so that local experts can modify MHF program components to reflect the realities of their current situations. This approach grounds the MHF program on the principle that mental health care is a combination of both universally applicable and context-specific knowledge and skills.
Individuals seeking MHF training represent a broad cross-section of local society ranging from school principals to business owners. The diversity of trainee backgrounds increases the possibility of addressing as many gaps as possible in local mental health care. The simplicity and portability of the MHF training program allows for governments and non-governmental organizations (NGOs) to position mental health interventions where they are most needed (Paredes, Schweiger, Hinkle, Kutcher, & Chehil, 2008). This flexibility can help policy-makers, service providers, communities, and NGOs meet local mental health needs without costly investments in infrastructure.
The MHF process identifies stakeholders who have the willingness and ability to further local mental health capacity. As countries recognize the dearth of community mental health services and attempt to carve out services with a mental health focus, the MHF program assists by demonstrating how much can be done at the “street” or “trenches” level. This is a critical component of the MHF training program since local groups always have more of a stake in risk reduction and capacity building than agencies outside of the local neighborhood, village or barrio (Abarquez & Murshed, 2004).
As local stakeholders are identified and trained with the 30-hour MHF curriculum, they become the foundation on which to build community mental health services and potentially funnel appropriate people for further mental health training. For example, the MHF program in Bhutan has led to specified substance abuse training in several communities as well as two students seeking graduate degrees in counseling in the U.S. These students, upon graduation, will be able to assist with what the WHO estimates to be at least 450 million people worldwide who live with mental health problems without services (WHO, 2005). Globally, one in four people will experience psychological distress and meet criteria for a diagnosable mental health disorder at some point in their lives. This ominous data speaks to the need for accessible, effective, and socially equitable mental health care (Hinkle & Saxena, 2006), upon which the MHF program can make an impact.
Unfortunately, many people in developing countries lack opportunities for mental health skill development and capacity building (Abarquez & Murshed, 2004). But, long years of training are not necessary to learn how to provide basic help for people who are emotionally distressed. For example, volunteers and community workers are a huge untapped source of service providers for people suffering mental distress (Hoff, Hallisey & Hoff, 2009). Enhancing community interventions, despite recent global political and economic policies that depart from such a model, is the only viable way to assist the never served. The MHF program can help to reverse this trend that has already begun in communities in Canada, Europe, Africa and the U.S. (Hoff, 1993; Hoff et al., 2009; Marks & Scott, 1990; McKee, Ferlie, & Hyde, 2008; Mosher & Burti, 1994; Rachlis & Kushner, 1994).
Moreover, people who obtain MHF training can serve as community leaders that develop “upstream” versus “downstream” care as well as serve as critical links to professional care (Hinkle, Kutcher, & Chehil, 2006; Hoff et al., 2009; McKinlay, 1990). Furthermore, MHFs working in communities can apply primary prevention principles by anticipating services for people who may be vulnerable to mental health distress. When services are available at the secondary prevention level, people with mental health disturbances can often avoid disruptive and costly hospitalization. Similarly, MHFs can assist with reducing the long-term disabling effects among people recovering from a mental disorder by applying tertiary prevention (Hoff et al., 2009).
Mental stress, distress and disorders go largely untreated in many areas of the world, especially when crises and disasters have struck. It is all too often the scenario where an earthquake, typhoon, hurricane, or man-made crisis such as war has occurred and following the event, no services for mental health care are available. In addition to governmental responses, NGOs, community and religious organizations attempt to provide assistance in the aftermath of disasters (Hinkle, 2010). For instance, MHFs from Lebanon to Liberia have assisted with mental health following civil war and refugee crises, and MHFs in China have assisted in the aftermath of earthquakes. Regardless of the genesis of the issue, many mental health-related concerns are largely dependent on problem-solving abilities, a focus on cultural values regarding mental health functioning, and social and economic support (Hinkle et al., 2006; Hoff et al., 2009).
Individuals within their communities who have completed the MHF training can effectively identify and meet community mental health needs. The MHF program is designed to teach people how to meet global mental health needs in a practical, effective, locally appropriate and standardized manner. The MHF process is based on establishing relationships that promote a state of mental health well-being, thereby enabling individuals to realize their abilities, cope with the normal and abnormal stresses of life, work productively, and make a contribution to their communities. All of these endeavors also support human rights development, an important factor in promoting community mental health.
It is important to note that the MHF training program can be used to enhance care at various levels. Informal community care is characterized by community members, without formal mental health education, but having completed MHF training, providing needed first responder services. At this level, non-clinical forms of mental health care such as general assessment, social support to individuals, families and groups, are provided at the community level. MHFs are teachers, police officers, neighborhood workers, community leaders, NGO workers, and elders including indigenous healers. In fact, witch doctors have been trained in the MHF program in Malawi, Africa where they apply their fundamental first-contact mental health skills to identify, assess, assist and refer people in need of care.
Furthermore, at the primary health care level, general medical practitioners, nurses, and other health care personnel provide treatment and MHFs can be implemented to supplement their more formalized efforts. At the specialized services level typically found in general hospitals, MHFs can augment traditional inpatient services by working within the mental health team by providing family support and education, follow-up monitoring, and practical “in the trenches” assistance.
Ultimately, MHFs can bridge the gap between formal and informal systems of mental health care. MHFs can work effectively within all three systems simultaneously. Since MHF training is transdisciplinary, traditional professional helping disciplines are not highlighted. Alternatively, mental health care competencies are linked to population mental health needs rather than professional ideologies, making MHFs more effective at identifying and meeting community mental health needs, regardless of how they are manifested.
The MHF process provides equitable access to first-responder interventions including mental health promotion, advocacy, monitoring and referral. This process respects human dignity and rights, meets many population mental health care needs, and is based on current global and local socio-cultural, economic and political concerns. For example, disasters result in tremendous loss of property, resources and life. In addition, political, economic and social disruptions are common consequences that have mental health-related consequences (Hinkle, 2010).
The core competency areas in the MHF training program include helping skills, stress, distress and disorders, disaster, crisis and trauma response, suicide, local contextualizing of services and referral to more formal mental health services which includes the mechanism for developing collaborative community relationships to enhance mental health care (Sonne, 2012). For example, MHFs are taught how to assist when a person is suicidal and how to support the person in seeking professional help (WHO, 2006). Context-specific competencies ensure policy-makers that MHF training provides culturally relevant services to the local population.
The introduction of community MHF training can further the development and delivery of community based care consistent with WHO recommendations for addressing global mental health needs. Basically, the MHF process involves joining with the person seeking assistance, assessing the level of difficulty, identifying the concerns, problem-solving, and referral to more formal mental health care. This is done within a human development framework based on personal strengths and mitigation of significant stress, distress and disorder. The MHF program has recently been expanded to provide assistance in more established countries, as manifested in the program’s current popularity in the U.S. It is obvious that the challenges of unmet mental health needs impacts global societies and economies negatively. The transdisciplinary MHF training model can provide all countries with a human resource development strategy to effectively and equitably bridge the mental health care-need service gap, one country at a time.
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Dr. J. Scott Hinkle is the Director of Professional Development at NBCC-I. For further information on the MHF program, please contact Dr. Wendi Schweiger at email@example.com.