Developmental Approach to Mental Health
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The developmental approach to mental health aligns social workers’ commitment to the services they provide with the need to promote a fairer and more inclusive society. The 2030 Agenda for Sustainable Development’s vision is to leave no one behind – this is central to social work and lies at the core of mental health approaches. In the 2030 Agenda, mental health is associated with well-being, which is essential for human development. A developmental approach focuses on structural injustices that impede human progress and mental health. It is a holistic, human rights-based approach in which participation, social and economic development, micro and macro practice, and partnerships are equally important and are integrated to promote and protect mental health. The approach is in line with the new recovery-oriented human rights-based and strength-based approaches to mental health which position mental illness and mental health along a continuum of health and where service users’ participation is central. In keeping with a mental health recovery approach, a developmental approach uses social investment strategies and interventions on a continuum of micro and macro practice levels where service users’ rights, their participation, and social and economic development and inclusion are inherent to the process and outcomes. The chapter concludes that the developmental approach to mental health offers social workers a platform to promote and protect mental health on an individual, household, community, policy, and research level. Furthermore, in partnership with stakeholders, including service users, this approach to mental health contributes to sustainable development and promotes justice for all.
KeywordsDevelopmental approach Mental health Leaving no one behind Recovery Human rights Partnerships Sustainable development 2030 Agenda for Sustainable Development
The Global Agenda for Social Work and Social Development’s (2012) commitment to contribute to a more just, inclusive, and peaceful society is aligned with the United Nations (UN) 2030 Agenda for Sustainable Development to transform the world to a more “just, equitable, tolerant, open and socially inclusive world in which the needs of the most vulnerable are met” (UN 2015, p. 4). The developmental approach, which underpins both these agendas, creates a platform for social work to promote and protect mental health within a sustainable development framework.
The 2030 Agenda for Sustainable Development [hereafter 2030 Agenda] is a charter for the people and the planet in the twenty-first century. It recognizes that people are central in preserving the planet for current and future generations (UN 2015). The commitment of the 2030 Agenda to the notion that “[n]o one must be left behind” (UN 2015, p. 7) was strengthened by devoting the United Nations Development Programme (UNDP) 2016 Human Development Report to the theme of human development for everyone (UNDP 2016). Leaving no one behind is a universal aspiration that unites the globe in the commitment, in the words of Helen Clark, administrator of the UNDP, to the premise that “[h]uman development has to be sustained and sustainable and has to enrich every human life so that we have a world where all people can enjoy peace and prosperity” (UNDP 2016, p. iv). Leaving nobody behind is also central to social work and lies at the core of the call for mental health for all.
In the 2030 Agenda, mental health is associated with well-being (UN 2015), as captured in its vision: “A world with equitable and universal access to quality education at all levels, to health care and social protection, where physical, mental and social wellbeing are assured” (UN 2015, p. 2). Mental health is thus an essential and inseparable component of health. This implies that mental illness is also a mental health issue (Prince et al. 2007) – suggesting that it is possible for a person to have a mental illness and to experience mental health at the same time (Caplan 2010). This assertion is embedded in the updated 2014 World Health Organization’s (WHO) definition of mental health, which indicates that mental health is “a state of well-being in which every individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community.”
The definition reflects a shift in the dominant paradigm in the mental health field from the conventional social work approach in the late twentieth and twenty-first century, which was an expert-clinical approach, to one of recovery, collaboration, and human rights, focusing on strengths rather than weaknesses (Caplan 2010) as the key principles underlying a developmental approach to social work and mental health.
From a well-being perspective, mental health cannot be seen in isolation, separate from other spheres relevant for human development. This means that Goal 3 of the 2030 Agenda, namely, to “[e]nsure healthy lives and promote well-being for all at all ages,” is an integral part of all 17 sustainable development goals, as they “are integrated and indivisible and balance the three dimensions of sustainable development: the economic, social and environmental” (UN 2015, p. 2). This is an important premise in understanding a structural approach to mental health.
Those who use mental health services often face stigmatization and exclusion. These challenges are exacerbated by structural injustices, including inequality, poverty, unemployment, and factors such as gender, race, ethnicity, sexuality, and disability (Fawcett 2012). Caplan (2010, p. 74) alludes to the disabling effects of mental illness and how they can affect individuals in a multitude of ways, “depending on the severity, duration, treatment, and the support structure” available to those individuals. Furthermore, Caplan (2010, p. 74) asserts that the disabling effects cannot be seen in isolation – various socioeconomic factors influence mental health, such as “unemployment, poverty, relationship issues, lack of housing, stigma and discrimination, and difficulty functioning in everyday life.” Caplan (2010, p. 74) points out that these are “just a few of the many common impairments that affect individuals and families.” Mental illness imposes a significant economic burden, not just on the individuals with a mental disorder but also on households, communities, employers, the healthcare system, and government budgets (Foresight 2008; McCrone et al. 2008). It perpetuates the cycle of poverty by interfering with individuals’ capacity to function in paid or non-income roles, leading to decreased social and economic productivity. This explains why people with mental health problems are often the poorest of the poor, because it may be impossible for them and/or their caregivers to work (Jenkins et al. 2011).
The Human Development Report (UNDP 2016) states that whatever the reach of societal challenges may be, whether they are lingering (deprivations), deepening (inequalities), or emerging (violent extremism), most are mutually reinforcing and have an impact on people’s well-being in both the present and future generations. A developmental approach to mental health includes biopsychosocial approaches to mental health that explore social causative factors, which predominantly emphasize social determinants and a social framework in addressing them (Fawcett 2012).
To ensure human development for everyone, it is not enough to identify the nature and the reasons for the deprivation of those left out (UNDP 2016). The Human Development Report (UNDP 2016) asserts that some aspects of the human development analytical framework and assessment perspectives must be shown upfront to address the issues that prevent universal human development. Such aspects include “human rights and human security, voice and autonomy, collective capabilities and the interdependence of choices [which] are key for the human development of those currently left out” (UNDP 2016, p. iii). Other factors, such as gender, must also be considered to “assess and ensure that human development benefits reach everyone” (UNDP 2016, p. iii).
Human development is thus influenced by inequalities and structural injustices in society which should be addressed to ensure mental health and well-being for all. Fawcett (2012) suggests that in order to address inequalities, there needs to be a balanced focus on social, cultural, and economic conditions that support family and community life. A developmental approach to social work involves a holistic approach that integrates human, social, and economic development by taking the broader environmental context into consideration. Because it is embedded in a social justice- and human rights-based framework, a developmental approach to social work connects the micro/individual/personal level with the macro/political/structural level (Patel 2015). In this context, a developmental approach is about sustainable development with a global and national developmental agenda. According to the UN, “[s]ustainable development recognizes that eradicating poverty in all its forms and dimensions, combating inequality within and among countries, preserving the planet, creating sustained, inclusive and sustainable economic growth and fostering social inclusion are linked to each other and are interdependent” (UN 2015, p. 5). In social work’s commitment to leave nobody behind, a developmental approach to mental health therefore has to promote human development within the framework of sustainable development.
The chapter begins with a discussion of mental health in the context of vulnerability and protection. Next, mental health is discussed in relation to human development. A developmental approach to social work in promoting human development is then outlined in relation to its respective themes, namely, a human rights-based approach, people’s participation, the integration of social and economic development, the linking of micro and macro practice, and, finally, partnerships for development (Patel 2015). The conclusion summarizes the main points.
Mental Health, Vulnerability, and Protection
The factors that contribute to mental health and well-being interact with one another. These factors are individual attributes and behaviors, social and economic circumstances, and environmental factors (WHO 2012). Individual attributes relate to a person’s natural and learned ability to deal with thoughts and feelings and to manage him/herself in daily life (emotional intelligence), as well as the capacity to deal with the social world by participating in social activities, taking responsibility for and respecting the views of others (social intelligence) (WHO 2012). Social and economic circumstances refer to the fact that an individual’s capacity to develop and flourish is deeply influenced by his/her immediate social surroundings – including his/her opportunities to engage positively with family members, friends, and colleagues and earn a living for himself/herself. Restricted or lost opportunities to gain education and income are especially pertinent socioeconomic factors (WHO 2012). Environmental factors refer to the wider sociocultural and geopolitical environment in which people live, which can also affect an individual’s household or community’s mental health status, including levels of access to basic commodities and services (water, essential health services, and the rule of law). They also include exposure to predominant cultural beliefs, attitudes, or practices, as well as social and economic policies formulated at a national level. Discrimination, social or gender inequalities, and conflict are examples of adverse structural determinants of mental well-being (WHO 2012).
These factors can threaten or protect mental health – as Beckett (2006, cited in Fawcett 2012) argues, all people are vulnerable in some respects, and most people are potentially or actually vulnerable in relation to a very wide range of risks and various old and new forms of social exclusion. The WHO (2010) affirms that vulnerability can lead to poor mental health. If mental health is to be promoted for all from a developmental approach, the vulnerability of people with mental health problems cannot be omitted from the discussion.
Mental health problems lead to reduced development and increased vulnerability, which are reflected in poverty, inequality, social and economic exclusion, stigma, violence and abuse, and restricted exercise of civil and political rights. In turn, this situation may worsen already poor mental health, as it leads to hopelessness, sadness, social withdrawal, and problems with sleeping, eating, and concentrating (Drew et al. 2011). Poor mental health can be both a cause and a consequence of the experience of social, civil, political, economic, and environmental inequalities (Friedli 2009). Mental health conditions are more common in areas of deprivation, and, in addition to poor physical health and adverse life events, poor mental health is consistently associated with unemployment, less education, and low income or a low material standard of living (Friedli 2009). An ongoing cycle can develop involving vulnerable groups, mental health conditions, and adverse development outcomes which perpetuate existing vulnerability.
Cavill et al. (2017) caution that vulnerability itself is a risk factor for developing mental health problems and leads to stigma and marginalization, which further generates poor self-esteem, low self-confidence, reduced motivation, and less hope for the future. As the result of stigmatization and discrimination, the rights of people with mental health problems may be violated. Many are denied economic, social, and cultural rights with restrictions on their right to work and education, and they may be denied reproductive rights and rights to the highest attainable health (WHO 2013a).
Despite their vulnerability, people with mental health problems – including schizophrenia, bipolar disorder, depression, alcohol and drug use disorders, child and adolescent mental health problems, and intellectual impairments – have been largely overlooked as a target of development work (WHO 2013a). This is despite the high prevalence of mental health conditions, their economic impact on families and communities, and the associated stigmatization, discrimination, and exclusion (Ngui et al. 2010). Mental illness frequently leads individuals and families into poverty (WHO 2011). In some instances, people with mental health problems are homeless or unjustly imprisoned, which worsens their vulnerability (WHO 2013a).
A developmental approach to social work focuses on people who are vulnerable, not from a deficit point of view, but from a human rights- and strength-based perspective, to tackle inequalities and create opportunities for human development and growth. The developmental approach aligns the Agenda for Social Work and Social Development (2012) with the 2030 Agenda for Sustainable Development by committing social workers to leave nobody behind in the global action plan for the next 15 years (UN 2015).
Jenkins et al. (2011) indicate the three main approaches that have been used to improve mental health in low- and middle-economy countries. The first is the public mental health approach, which focuses on a combination of prevention and treatment of severe mental illness (SMI) such as schizophrenia and bipolar mood, as well as the integration of mental healthcare into existing health services. The second is the human rights-based approach, which emphasizes the deinstitutionalization of people with a chronic mental disorder/illness. The third is a developmental approach, which targets poverty reduction to expand access to health, and assumes that mental health will improve with increased national wealth. These three approaches, prevention and treatment, human rights, and poverty reduction, are combined in a developmental approach to social work and mental health within a sustainable developmental framework. In the context of this chapter, the call to leave nobody behind is about protecting and promoting mental health in relation to human development, which is discussed next.
Mental Health and Human Development
Human development is about people and human freedom: the freedom to realize the full potential of every human life – now and in the future (UNDP 2016). The two fundamental types of freedom for human development are freedom of well-being, represented by functionings and capabilities, and freedom of agency, represented by voice and autonomy (UNDP 2016). Functionings include the different things a person may “value being and doing – such as being happy, adequately nourished and in good health, as well as having self-respect and taking part in the life of the community.” Capabilities are the various sets of combination of functionings (beings and doings) that a person can achieve (UNDP 2016, p. 1). Agency is about having a voice and autonomy and to do or achieve what is valued (UNDP 2016).
Mental health is embedded in a set of functionings such as opportunities to learn and be educated in order to enhance capabilities, for example, to work and experience freedom from discrimination, being homeless, poverty, unemployment, and exclusion. Being treated with dignity is fundamental to developing agency. It is important for a person’s mental health to have a sense of self-worth and self-awareness, self-confidence, and self-esteem, have maturity to judge and make decisions, be able to form affectionate relationships, generate and sustain supportive networks, be able to tackle life’s tasks and deal with complex demands, and, “most important of all, hav[e] the capacity to grow as a person” (Fawcett 2012, p. 516).
Freedom, justice, and peace in the world are embedded in recognition of the inherent dignity and the equality and rights of people (UN 1948). Sen (1999) argues that there is a link between different types of freedom and distinct types of rights and opportunities. Mental health is a freedom and a human right which is embedded in social justice, which is a core value of social work. Isbister (2001) affirms that freedom can only reach its fullest potential in the presence of equality.
Therefore, making development matter for all people in the world, now and in the future, is a universal approach which lies at the core of the human development paradigm, acknowledging the life claims of everyone (UNDP 2015). From a structural point of view, the developmental approach is, first and foremost, about human development. In order to leave no one behind in its aspiration to promote mental health and well-being, the developmental approach is embedded in human rights and the call to achieve social justice within a sustainable development framework.
Developmental Social Work
A developmental approach to social work embraces a human rights-based approach, people’s participation, the integration of economic and social development, bridging micro and macro practice, and partnerships (Patel 2015). These elements, which are discussed below, are intertwined in promoting human development. They are underpinned by the five Ps of the 2030 Agenda, namely, people, the planet, prosperity, partnerships, and peace (UN 2015), all of which anchor the development approach in a sustainable development framework.
Human Rights-Based Approach
The human rights-based approach to development recognizes protection and promotion of human rights as an explicit development objective and encourages participation, long-term planning, and a multidimensional understanding of poverty (Drew et al. 2010). Drew et al. (2011) point out that people with mental health problems are often denied civil and political rights, such as the right to marry and find a family, personal liberty, and the right to vote and to participate effectively. The WHO (2013a) states that people with mental health problems are often denied the right to exercise their legal capacity on issues affecting them, including treatment and care. Furthermore, people with mental health problems often live in vulnerable situations and may be excluded from society, which constitutes a significant impediment to the achievement of national and international developmental goals (WHO 2013a).
Human rights are indivisible and interconnected (Ife 2012). Hence, civil and political rights; social, economic, and cultural rights; and environmental rights are all equally important to promote mental health. From a structural and social justice perspective, the lives of people with mental disorders can be improved through policies, plans, and programs that lead to better services in general and for this vulnerable group in particular (WHO 2005). Declarations and treaties play an important role in progressive mental health policies that seek to increase opportunities for people with mental disorders to live fulfilling lives in the community.
International human rights documents broadly fall into two categories: ones that legally bind states that have ratified such conventions and ones that are referred to as international human rights standards, which are considered guidelines enshrined in international declarations, resolutions, or recommendations, issued mainly by international bodies (Freeman and Pathare 2005). Examples of the first kind of document are international human rights conventions, such as the International Covenant on Civil and Political Rights (ICCPR) (UN 1966a) and the International Covenant on Economic, Social and Cultural Rights (ICESR 1966b). The second category includes UN General Assembly Resolutions such as the Principles for the Protection of Persons with Mental Illness and the Improvement of Mental Health Care (UN MI Principles 1991). The second category of documents are not legally binding, but they can and should influence legislation in countries, since they represent international consensus (WHO 2010).
The WHO (2008) indicates that the adoption of the UN Convention on the Rights of Persons with Disabilities (CRPD) in 2006 was a major step forward in improving the lives of people with mental health problems. Moreover, the WHO (2013a) asserts that this marks a paradigm shift away from viewing people with disabilities as objects of charity toward viewing them as bearers of human rights with the capacity for self-determination. Notably, the CRPD provides a comprehensive legal framework for ending the discrimination experienced on a daily basis by many people with mental health conditions. It protects and promotes their rights and promotes their inclusion in international cooperation, including international development programs (WHO 2013a).
The African (Banjul) Charter on Human and Peoples’ Rights (1981) is a legally binding document supervised by the African Commission on Human and Peoples’ Rights. The instrument contains a range of important articles on civil, political, economic, social, and cultural rights. Clauses pertinent to people with mental disorders include Articles 4, 5, and 16, which cover the right to life and the integrity of the person, the right to respect of dignity inherent in a human being, and the prohibition of all forms of exploitation and degradation (WHO 2010).
The European Convention for the Protection of Human Rights and Fundamental Freedoms (1950), backed by the European Court of Human Rights, provides binding protection for the human rights of people with mental disorders residing in all the states that have ratified the Convention (Drew et al. 2011).
There are several human rights standards applicable to mental health. Firstly, the UN principles for the protection of persons with mental illness and improvement of mental healthcare (UN MI principles 1991) serve as a framework for the development of mental health legislation in many countries. Secondly, the Standard Rules on the equalization of opportunities for people with disabilities reiterate the goals of equalizing opportunities established by the World Programme of Action (WHO 2005).
The Declaration of Caracas (1990), adopted as a resolution by legislators, mental health professionals, human rights leaders, and disability activists convened by the Pan American Health Organization (PAHO/WHO), has major implications for the structure of mental health services. It states that exclusive reliance on inpatient treatment in a psychiatric hospital isolates patients from their natural environment, thereby generating greater disability. The Declaration establishes a critical link between mental health services and human rights because it concludes that outmoded mental health services put patients’ human rights at risk. It aims to promote community-based and integrated mental health services by suggesting that existing psychiatric care should be restructured (Drew et al. 2011).
The Madrid Declaration on Ethical Standards for Psychiatric Practice adopted by the General Assembly of the World Psychiatric Association (WPA) in 1996 is an example of an international association of mental health professionals’ attempt to protect the human rights of persons with mental disorders by issuing its own sets of guidelines for standards of professional behavior and practice (WHO 2010). Among other standards, the Madrid Declaration insists that treatment should be provided in partnership with persons with mental disorders and that involuntary treatment can only be enforced in exceptional circumstances (WHO 2010).
Based on various declarations and treaties, many progressive mental health policies have sought to increase opportunities for people with mental disorders to live fulfilling lives in the community. Freeman and Pathare (2005, p. 4) indicate that legislation can foster such opportunities if it prevents inappropriate institutionalization and provides for appropriate facilities, services, programs, personnel, protections, and opportunities to allow people with mental disorders to thrive in the community. This suggests that legislation plays a role in ensuring that a person suffering from a mental disorder can participate in the community. The prerequisites for such participation include access to treatment and care, a supportive environment, housing, rehabilitative services (e.g., occupational and life skills training), employment, nondiscrimination and equality, and civil and political rights (such as the right to vote, drive, and access courts) (Freeman and Pathare 2005).
The human rights-based approach to development recognizes the protection and promotion of human rights as an explicit development objective and encourages participation, long-term planning, and a multidimensional understanding of poverty (Drew et al. 2010). This understanding is important in tackling the inequalities that contribute to mental illness and in advocacy for socioeconomic rights and the inclusion of people affected by mental illness. Green (2012) argues that people’s right to socioeconomic development is related to concepts of citizenship, participation, and power, which underscores the importance of the participation of service users in mental health planning and activities.
Mental health legislation, or mental health provisions integrated into other laws for example, anti-discrimination, general health, disability, employment, social welfare, education, housing, and other areas may cover a broad array of issues including access to mental health care and other services, quality of mental health care, admission to mental health facilities, consent to treatment, freedom from cruel, inhumane and degrading treatment, freedom from discrimination, the enjoyment of a full range of civil, cultural, economic, political and social rights, and provisions for legal mechanisms to promote and protect human rights, for example, review bodies to oversee admission and treatment to mental health facilities, monitoring bodies to inspect human rights conditions in facilities and complaint mechanisms.
Developmental social work emphasizes the inclusion of people’s voices in their own development (Lombard 2014). A developmental approach thus recognizes that people with mental health problems are key actors in their own development, rather than merely passive recipients of commodities and services (WHO 2010). Caplan (2010) points out that the power of participation in the mental health field is now well established in the recovery vision for mental health, which is an initiative articulated by service users. Service users define recovery in terms of what is important to them (Fawcett 2012). In this context, Double (2002, quoted in Fawcett 2012, p. 525) avers that recovery “is not about becoming symptom free, but about reclaiming an individually determined and socially valued lifestyle, retaining control over decision-making processes, and utilising advance directives if necessary.”
A recovery-oriented approach assumes that individuals have the capacity to take responsibility for their lives (Bila 2017). Empowerment is therefore central in recovery-oriented mental healthcare. Slade (2009) explains that empowerment emerges from agency beliefs and involves behavior that has a positive impact on people’s lives. Contrary to older approaches that regard the person as the problem, there has been a fundamental shift in the recovery perspective to mental health toward seeing the person as part of the solution.
Having agency and a voice is about enlarging people’s freedoms so that they can pursue the choices that they value in building their capabilities (UNDP 2016). Human development therefore implies that people must influence the processes that shape their lives, including mental health recovery through active participation (UNDP 2016). It is not only important that people with a mental illness have choices in their treatment but also that they have a choice about participating in society. Therefore, people with mental health problems should be supported to participate in development opportunities in their communities (Janardhana and Naidu 2012). Self-determination can be achieved on both individual and collective levels. Hence, service users, as a distinct group, should be included as equals in policy and service decisions (Caplan 2010). From a developmental approach perspective, service users are key partners in their recovery. Their inclusion also applies to decisions on development and poverty reduction activities such as education, employment and livelihood programs, and the human rights agenda (WHO 2013b), all of which are essential components for social and economic inclusion.
Integrating Social and Economic Development
Given the strong role of social determinants in mental health, rehabilitative interventions must also address poverty reduction (Jenkins et al. 2011). Mental health conditions are associated with high rates of unemployment (WHO 2010), and therefore livelihood interventions are increasingly linked to mental health interventions (Baingana 2011). Chisholm (2013) indicates that grants and support for small business operations have demonstrated benefits, not only for people with mental health conditions but also for their families and communities, which can strengthen their capacity and enable them to participate fully in public affairs.
The recovery vision that emphasizes that each individual has unique talents to have a meaningful and productive role in society, either as an individual or as a collective, harmonizes with a social investment approach to mental health (Caplan 2010). The social investment approach is a strategy toward prosperity and sustainable livelihoods. The premise of a social investment approach is “that economic development must promote social welfare and that social welfare interventions, in turn, must promote economic development, that interventions are not consumption-based but are productive and driven by consumers [service users], and that human rights are at the forefront of all efforts” (Caplan 2010, p. 78). Consumers refer to people with mental illness who are service users of mental health services. Social investment strategies build on people’s capabilities to be productive citizens and lead normal and fulfilling lives (Midgley and Conley 2010). Social enterprise is an innovative social investment strategy in mental healthcare and other disabilities to foster social and economic development and inclusion (Caplan 2010).
Social investment, as in the case of recovery, nurtures the skills and knowledge of people and encourages participation in education, community involvement, and employment to develop and use these talents (Caplan 2010). Integration of social and economic development strategies is important for human development and in particular for service users who have a say in their recovery. Social investment strategies contribute to building social capital, which is important for service users to develop cohesive relationships through mental health peer support groups (Caplan 2010). Furthermore, social investment strategies strengthen mental health service users’ right to socioeconomic development and the development of their capabilities to live independent lives. It provides “opportunities for the social inclusion for some of the most marginalised people in society, working with them to overcome the experiences of isolation and stigma that are often the most debilitating effects of mental illness” (Caplan 2010, p. 71). Both micro and macro interventions are required to create opportunities for social and economic inclusion.
Linking Micro and Macro Practice
As indicated above, mental health, like other aspects of health, can be affected by a range of socioeconomic factors that must be addressed through a comprehensive strategy of promotion, prevention, treatment, and recovery (WHO 2013b). The developmental approach’s focus on both micro and macro interventions is aligned with the recovery focus in mental health, which Caplan (2010, p. 71) refers to as “a new paradigm in the conceptualization, discourse, and treatment of mental health.” This shift was sparked by the “advocacy of mental health consumers and [is] grounded in the concepts of hope, relationship, meaningful activity, empowerment, self-determination, and education” (Caplan 2010, p. 71). In this framework, recovery does not necessarily mean the absence of illness; rather, it describes the ability to cope with the symptoms of a mental illness and have quality of life in whatever way is significant for the individual (Caplan 2010). Recovery can also be viewed as learning how to cope effectively, not only by addressing the symptoms of mental illness but also by overcoming its negative consequences (to which social stigma contributes considerably), such as homelessness, unemployment, or problems with relationships (Caplan 2010).
Similar to the argument that people can and do recover from mental illness to lead fulfilling and meaningful lives (Caplan 2010), a developmental approach does not discard the remedial or treatment approach but accommodates its implementation through human rights- and strength-based approaches. In promoting mental health, the emphasis should therefore be on services, policies, legislation, plans, strategies, and programs that protect, promote, and respect the rights of people with mental health problems (WHO 2013b).
Through a micro-macro practice lens, recovery is seen as lying on a continuum, ranging from the individual/personal intervention level, including treatment and development of agency, to the macro/political level where advocacy practice is important in challenging and breaking down inequalities that impede socioeconomic development and inclusion. Linking micro and macro practice interventions is therefore an important feature of developmental social work in shifting from a remedial or clinical perspective to a structural perspective that exposes injustices and abuses of human rights and, most importantly, addresses the socioeconomic factors that impede mental health and human development. On a macro level, it requires engagement on a political level to influence policy through advocacy practice. Funk (2010) indicates that targeted policies, strategies, and interventions for reaching people with mental health conditions should be developed and mental health interventions should be mainstreamed into broader poverty reduction programs. Mainstreaming involves the elements of participation, accountability, nondiscrimination, empowerment, and an explicit linkage to human rights standards (Department of Social Development 2013; Baingana 2011). To make implementation a reality, adequate funds must be dedicated to mental health interventions and mainstreaming efforts. Furthermore, service providers should be encouraged to address the needs of people with mental health problems as part of their development work (Drew et al. 2011). In this regard, Fawcett (2012, p. 515) refers to the challenge to make what she calls “underfunded systems” actually work, which is an important issue for social work advocacy on a macro level.
Linking micro and macro practice interventions emphasizes the holistic nature of a developmental approach. The approach sees recovery as lying on a continuum where human rights, participation, and social and economic development play an inherent role in influencing the “core concepts of recovery.” These concepts are self-direction, hope, empowerment, the involvement of supportive personal relationships, having a meaningful role in society, and a process of nonlinearity – meaning to be flexible in achieving recovery (Caplan 2010, p. 79). Shifting the continuum of recovery to a full circle requires active partnerships among various stakeholders.
Partnerships for Human Development
The premise of recovery-oriented mental health approaches is that everyone should be involved in mental health services and that everyone should be given opportunities to work together and integrate various skills and experiences to promote and protect mental health (Bila 2017). Therefore, mental health partnerships cut across all sectors on global and national levels, including governments, nongovernmental organizations (NGOs), community-based organizations (CBOs), the private sector, ordinary citizens, and service users.
The importance of partnerships is reiterated on a global level in the 2030 Agenda for Sustainable Development, where one sustainable development goal (SDG) has been dedicated to this end. SDG 17 reads: “Strengthen the means of implementation and revitalize the Global Partnership for Sustainable Development” (UN 2015, p. 26). The partnership goal applies to the remaining 16 SDGs. This includes SDG 3, which relates to health and mental health and well-being. Fawcett (2012, p. 526) explains the global link of mental health, commenting: “Across the globe, improving mental well-being, preventing mental ill-health, and responding to mental distress in all its manifestations are key concerns.” WHO (2010) emphasises that support for opportunities for exchange between countries on effective policy and legislative intervention strategies to promote mental health, prevent mental illness, and promote recovery from illness based on the international and regional human rights framework is vital. Partnerships thus play an essential role in sustainable human development and hence in mental health and well-being.
States that are signatories of the 2030 Agenda declaration have committed themselves to a collaborative partnership that will forge transformation of the world through achieving the sustainable development goals. In the commitment to leave no one behind, they promised the following: “As we embark on this great collective journey, we pledge that no one will be left behind” (UN 2015, p. 3).
From a global perspective, all governments should work along with the WHO, which is responsible for “promoting measures which focus on mental health promotion and mental ill-health prevention on reducing inequalities within and between nations” (Fawcett 2012, p. 526). However, the WHO (2013b) asserts that of all development stakeholders, governments play the most important role in creating enabling environments, reducing stigma and discrimination, promoting human rights, and improving the quality and quantity of services (education, health, social services, and poverty alleviation). From a human rights-based perspective, governments have a duty to promote and protect mental health and well-being for all and should be held accountable by civil society in the fulfilment of this duty. Commitment to the 5-year action plan to achieve the 17 SDGs and its 167 targets includes the government’s duty to implement commitments such as the Accra Agenda for Action, the CRPD, and other human rights conventions (McInerney-Lankford and Hans-Otto 2010).
The new focus on recovery, which has progressed from the lived experiences of people who use such services (Care Services Improvement Partnership [CSIP] 2007), emphasizes the key role that they have to play in mental health partnerships. In this regard, Fawcett (2012) points out that service users’ perspectives are gaining ground and that many public services in countries such as Australia and especially the UK now employ service user advocates. However, this has not escaped implementation challenges. Hence, Fawcett (2012) emphasizes the importance of staff training, good use of resources, and effective communication and support systems to enable agencies and organizations to foster links with service user movements.
Partnerships should also be developed with the broader community from which service users come. Bracken and Thomas (2004, p. 13) argue that problems such as poverty and unemployment are social and not individual problems. Because they are “at the heart of mental health crises,” they also require social responses (Bracken and Thomas 2004, p. 13). Services provided by civil society can include healthcare, social services, education programs, and livelihood projects (Fawcett 2012, p. 515). In addition, the WHO (2010) states that civil society can play an important role in supporting people with mental health conditions to access the resources they need and to integrate fully into the community through direct service provision and advocacy.
Partnerships in the community should support the creation and promotion of associations and organizations for people with mental health problems, as well as for their caregivers (WHO 2013b). Dialogue between health workers; government authorities in the areas of health, human rights, disability, education, and employment; and the judiciary is important in supporting and strengthening service users, caregivers, and associations and organizations who work with people with mental health problems to integrate recovery services (WHO 2013b). In addition, the WHO (2010) states that strong links should be developed between mental health services, housing, and other social services, because mental health conditions often coexist with a number of other problems, such as homelessness. Furthermore, the WHO (2013b) indicates that civil society can advocate and lobby the government and funders to recognize and support people with mental health conditions. In order to improve development outcomes, government can provide support to build and strengthen mental healthcare users’ groups and offer opportunities for these groups to express their views and participate in decision-making processes (WHO 2013b).
Medical-legal Partnerships (MLPs) have recently emerged in the global mental health environment as a new private initiative to enhance mental health service users’ rights to recovery. An established network of MLPs operates in various contexts in the USA, including general practice medicine and specialized services, such as psychiatry and social work (Cohen et al. 2010). MLPs are joint ventures between lawyers and medical professionals that integrate legal assistance with a medical setting. The purpose is for partners to seek to identify and resolve legal issues that have an impact on patients’ health and well-being (Cohen et al. 2010).
MLPs provide legal assistance in areas such as income support, rights to divorce, education, guardianship and power of attorney, and issues pertaining to tenancy (Zuckerman et al. 2008). Ryan et al. (2012) highlight three key activities in which MLPs engage: providing legal help in a healthcare location, transforming the practices of legal and health institutions, and influencing policy change. Cohen et al. (2010) assert that evidence shows that the availability of legal support and services to those who are disadvantaged significantly influences their health. Through an MLP, legal practitioners can support the reduction of psychological stress of a person with mental health concerns by being present and available to resolve issues such as tenancy, fines, and custodial orders, which are issues that can exacerbate the deterioration of the person’s mental health (Ryan et al. 2012).
MLPs strengthen the human rights-based basis of the developmental approach to mental health. This facilitates the engagement of partnerships on a legal basis. It creates space for partnerships between professionals such as lawyers, medical professionals, psychologists, and social workers (Colvin et al. 2011). Furthermore, collaborations between physicians, nurses, social workers, and attorneys enhance service delivery, helping it to meet the needs of families who require a one-stop service. Colvin et al. (2011) have highlighted the integral role that social workers play in an MLP and argue that MLP team members recognize the need for teaching and adopting social work’s empowering approach, which is important in achieving social justice for all. Rand (2006) affirms that the empowerment approach can enhance social justice and systemic changes adopted by lawyers and other MLP team members. MLP strategies are developmental, but their impact in a broader sustainable development context in fostering social and economic inclusion of mental health service users is determined by their availability and accessibility to all mental health service users but in particular by those that are mostly affected by structural injustices.
The emphasis on structural injustices shows that research can and should play an important role in a developmental approach. This implies that research institutions are important partners in mental health recovery. Drew et al. (2010) call on academic and research institutions to improve development outcomes by generating and synthesizing policy-relevant research findings, as well as building capacity to conduct and interpret research at local levels. These authors argue that research which is properly formulated and conducted can inform the planning and implementation of development programs and the allocation of scarce human and financial resources. Academic and research institutions should play a key role both in building and managing knowledge and in building the capacity of policymakers, planners, and service providers from different sectors (Drew et al. 2010).
The importance of partnerships in relation to the other themes of a developmental approach, as well as the overall responsibility of governments to promote citizens’ mental health and well-being on all levels, can be demonstrated as the key direction for public mental health promotion and protection for individuals, households, communities, and vulnerable groups, who are all important stakeholders in recovery partnerships.
The WHO (2012) advocates for public mental health responses across these levels by means of a number of key strategies and interventions which provide a platform for developing strong partnerships among all stakeholders involved in mental health promotion, protection, and recovery. These strategies and interventions are summarized below in three broad categories.
Developing and Protecting Individual Attributes
Mothers and infants: Enabling early attachment, providing appropriate parenting training and natal care (including postdepression care, developing safe, stable, and nurturing relationships between children and their parents and caregivers)
Children and adolescents: Ensuring sufficient nutrition and stimulation
Older adults: Implementing healthy aging policies and community activities
All age groups: Encouraging regular physical activity and a healthy diet; discouraging or restricting the use of tobacco, alcohol, and other psychoactive substances
Supporting Households and Communities
Families: Ensuring secure living conditions for children and adolescents, targeting prevention at those with behavioral disorders and those with a parent with mental illness, and preventing intimate partner violence
Workers/employees: Supporting increased employment opportunities and promoting safe and supportive working conditions (including stress management)
Low-income households: Ensuring basic living conditions (shelter, water, and sanitation) and providing social and financial protection
Communities: Making neighborhoods safe, enhancing civic assets/social networks, and restricting the availability of alcohol, drugs, and tobacco
Supporting and Protecting Vulnerable Groups in Society
Developing and implementing social inclusion policies
Implementing anti-discrimination laws and policies
Making education available and accessible to all
Promoting women’s rights and freedoms and gender-equity policies
Providing early intervention to refugees after exposure to trauma (including those caught up in conflict)
Conducting awareness-raising campaigns
Fostering responsible reporting in the media
The proposed strategies and interventions illustrate that mental health rests on individuals’ capacity to manage their thoughts, feelings, and behaviors, as well as their interactions with others (WHO 2005). It is essential that these core attributes of self-control, resilience, and confidence be allowed to develop and become ingrained in the formative stages of life, so that individuals are equipped to deal with the complex choices and potential adversity they may face as they grow older (WHO 2004). Promoting a healthy start in life is therefore vital (WHO 2004).
On an individual level, mental health and well-being are strongly mediated by the immediate social context in which people live, work, and carry out their day-to-day activities (Tol et al. 2011). At a family and community level, the focus is therefore on fostering living and working conditions that enable psychosocial development and promote positive interactions within families and social groups (WHO 2010).
The proposed strategies and interventions relate to the recovery continuum of micro and macro practice, which underpin the other themes of a developmental approach, namely, human rights, participation, the integration of social and economic development, and partnerships.
Social workers who adopt a developmental approach to mental health commit to challenging and addressing structural injustices and inequalities to promote a more just and inclusive society for all. In social work’s commitment to leave nobody behind, a developmental approach creates a platform to promote and protect mental health within a sustainable development framework.
Mental health and well-being are essential for human development. A developmental approach to mental health is in line with a recovery-oriented, human rights-based approach to mental health, presented on a continuum of micro and macro practice interventions that emphasize treatment, protection, prevention, and promotion. The underpinning themes of a developmental approach, namely, human rights, participation, the integration of social and economic development, the linking of micro and macro practice, and the development of partnerships, are interrelated. Hence, those who adopt such an approach embrace a holistic approach to mental health promotion, protection, and recovery. Within the framework of sustainable development, a developmental approach values people, the planet, prosperity, partnerships, and peace in its pursuit to leave no one behind (UN 2015) and achieve social justice for all.
Partnerships are essential for human development and mental health and well-being. Improving development outcomes for vulnerable groups should be a priority for partners in mental health promotion and protection. Social investment strategies are important to address the structural determinants that contribute to and exacerbate mental distress and illness. Such strategies are essential to strengthen mental health service users’ agency, capabilities, and livelihoods, enabling them to live independently.
All development stakeholders have a responsibility to ensure that the rights of people with mental health conditions (as a vulnerable group) are protected. This means making sure that they are provided with opportunities to improve their living conditions and lead fulfilling lives within their communities. Government in particular must play a key role in creating an enabling environment to promote and protect mental health, and government should be held accountable by all stakeholders to deliver on this duty.
Finally, Fawcett (2012, p. 515) calls on social workers to pose critical questions and look creatively at options for what she calls a more “responsive mental health practice.” The developmental approach to mental health is such a response: it offers a platform for social workers to promote and protect mental health on an individual, household, community, policy, and research level and, in doing so, to contribute to sustainable development and promote justice for all.
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