Rethinking Mental Healthcare

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This quarter I am enrolled in Refugee & Immigrant Health, a core class in the global health department taught by Bechara Choucair. The class discusses a wide range of topics related to the health challenges of these population groups including infectious disease, access to care, and mental health. Last week Mary Fabri, a trauma & mental health specialist, came to speak with us about trauma treatment and her work with former Sri Lankan child soldiers.

The Sri Lankan Civil War started in 1983, when an independent military organization known as the Liberation Tigers of Tamil Eelam (LTTE) wanted to create an independent Tamil State. The war waged for 27 years, during which an estimated 80,000-100,000 people perished. The LTTE also heavily recruited an estimated 6,000 child soldiers, both for use on the front lines and to be taken as “wives.”

How do we rehabilitate and reintegrate children that have experienced such atrocious trauma? The Professional Psychological Counseling Centre (PPCC), a local organization in Sri Lanka, and Heartland Alliance, a service-based human rights organization based in Chicgao, IL, sought to tackle this issue through Cuckoo’s Nest, a 6-month residential rehabilitation service for former LTTE child soldiers in Batticaloa, Sri Lanka. With the ultimate goal being reintegration, this program took a multifaceted approach: vocational training, basic language and literacy skill training, and trauma-informed group and individual counseling. The vocational training included tailoring, carpentry, electrical wiring, welding, and beauty services. The trauma-informed components psychoeducation, cognitive restructuring, problem solving, and anger management.

The results were rather dramatic. Children who met the criteria for Post-Traumatic Stress Disorder dropped from approximately an 80% baseline to just over 20% at graduation. Rates of moderately severe to severe depression also dropped, with a baseline of approximately 60% for girls and 30 % for boys, but little to none at graduation. One of the children stated, “These activities have changed me into a human person, have given me happiness and confidence, and have given me a desire to live.”

However, the top three activities that the children listed as most helpful would not traditionally be thought of being associated with mental health treatment: vocational training, meditation and yoga, and literacy skills. The vocational training could have also given the children a profound purpose in their home once they returned. Child soldiers can often be harshly stigmatized when they return to their homes post-conflict, being seen as criminals or sexually unclean. However, having a utility within the likely poverty-stricken home environment could help lessen the shame cast upon them. Meditation and yoga are a culturally sensitive way that the children could work on relaxation training and the mind-body connection. Additionally, literacy skills could have increased the children’s sense of control and self-esteem.

I believe that Cuckoo’s Nest is a prime example of how we should take more multidisciplinary approaches in mental healthcare. Our behavioral and emotional well-being are not separated from our daily lived experience, so perhaps they should not always be treated like they are. Treatments such as individual counseling unquestionably have benefits, but may be too abstract for a child to fully utilize to their benefit. Cuckoo’s Nest is an interesting example of a comprehensive, culturally-specific, and effective treatment plan for a specific patient population. It also raises further questions such as, if and how can we seamlessly integrate mental health supports into primary care models that may seem less formal than individual therapy. Because of the harsh stigma regarding mental health, policy may need to focus on how it can be assimilated into other forms of healthcare, and even daily activities.

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One Comment:

Posted by Grace on

Given the dearth of treatments for mentally ill children, I found your blog to be a provocative and timely post that emphasizes the need for change. Too much of our time is spent debating how to screen school children for signs of mental illness rather than providing assistance. It surprises me that the activities children found most helpful—vocational training, meditation and yoga, and literacy skills—are not traditionally considered as mental health treatment. As you stated, these activities helped children improve their self-esteem and gave them “a profound purpose.” I think it is important to take a similar approach to mental health treatment and aim for social integration. This begs the question, why does the current mental healthcare system focus primarily on providing individual counseling rather than group support and social integration? Is it due to the stigma? Only recently are programs, such as the Assertive Community Treatment, seeking to connect mentally ill teens with others. Individual counseling may be “too abstract,” while a program like Cuckoo’s Nest that allows children to connect with peers can prove more beneficial. Cuckoo’s Nest can also relieve parental stress that comes from taking care of a mentally ill child. Gianni’s mother notes that during her son’s “episodes” in which he says he will kill the family, she fears for her safety and worries of protecting her other children. Through residential programs like Cuckoo’s Nest, mental health professionals can provide the necessary help in emergency situations and reduce some of the stress parents carry. Moreover, Cuckoo’s Nest can help prevent tragic incidents such as the death of Keith Vidal, a teenager who was shot this January by a police officer when his family called for help.

Despite the benefits of Cuckoo’s Nest, I wonder if it would be feasible to adopt a similar approach in mental health treatment. When you state that Cuckoo’s Nest is a “prime example” to follow, are you assuming it will yield the same impressive results in mentally ill children, such as a 60% reduction in the number of students who met the criteria for PTSD? While the program was designed for child soldiers suffering from PTSD and depression, disorders such as schizophrenia have a biological basis of disease that may render change difficult. With regards to the question you raised on whether mental health services like Cuckoo’s Nest can be integrated into primary care models, let me note that it has been successfully accomplished in the past by the Cherokee Health Systems in 1984. The World Health Organization also recommends integration of mental health services with the primary care model due to the various benefits, including improved access to care. With an added goal of improving self-esteem and social integration, the new model shows more therapeutic potential. More importantly, however, even without integration into primary care models, I argue that the establishment of programs like Cuckoo’s Nest alone can add a humane component and serve as a catalyst in reducing the stigma attached to mental illness.

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