Historicising involvement: the visibility of user groups in the modernisation of the Chilean Mental Health System

Misunderstood and underappreciated: a critical review of mental health advocacy and activism in low- and middle-income countries

Mental health advocacy and activism have been highlighted as important in the effort towards creating environments for better mental health. However, relevant research in low- and middle-income country settings remains limited and lacks critical exploration. We seek to contribute to filling this gap by exploring driving factors behind mental health advocacy and activism efforts in low- and middle-income country settings. This review uses a critically informed thematic analysis employing conceptual frameworks of productive power to analyse peer-reviewed articles on mental health advocacy or activism over the last 20 years. We suggest that the current body of research is marred by superficial explorations of activism and advocacy, partly due to a lack of cohesion around definitions. Based on our findings, we suggest a conceptual framework to guide deeper explorations of mental health advocacy and activism. This framework identifies 'legitimacy', 'context' and 'timing' as the main dimensions to consider in understanding activism and advocacy efforts. The fact that they remain misunderstood and underappreciated creates missed opportunities for meaningful inclusion of lived experience in policy decisions and limits our understanding of how communities envision and enact change.

Mad activisms in mental health: a integrative review

The following text presents the results of a integrative review whose purpose was to identify and analyze the production of academic literature on mad activism in the field of mental health and its link with the notions of disability and neurodiversity. From searches conducted in May 2023 in the Web of Science, Scopus, and PubMed databases, 52 articles were selected, and thematic content analysis strategies were applied. The results account for various articulations between the concepts addressed, establishing a critical look at the biomedical model in mental health. In the forms of mad activism, the human rights approach, the fight against stigma and its influence on the reform processes of the mental health system become relevant. On the other hand, a framework of social justice, identity policies and practices of mutual support from the community are established. As a whole, they emphasize methodological innovations and an intersectional perspective on the production of knowledge. It is concluded that it is possible to situate madness as a field of constitution of a political actor and epistemic subject. Based on this, possible lines of research on mad activisms in Latin America are formulated.

Using participatory action research to reimagine community mental health services in Colombia: a mixed-method study protocol

INTRODUCTION

Mental healthcare systems are challenged by how they hear and respond to what marginalised communities experience as drivers of mental distress. In Colombia, this challenge intersects with wider challenges facing post-conflict reconstruction. Our pilot study will explore the feasibility and acceptability of a participatory approach to developing community-led participatory interventions for community mental health systems strengthening and mental health improvement, in two sites in Caquetá, Colombia.

METHODS AND ANALYSIS

The project is divided into three distinct phases aligned with community participatory action research cycles: diagnostic, intervention and evaluation. This allows us to use a participatory approach to design a community-led, bottom-up intervention for mental health systems strengthening and the promotion of mental health and well-being.The diagnostic phase explores local understandings of mental health, mental distress and access to mental health services from community members and health providers. The intervention stage will be guided by a participatory Theory of Change process. Community priorities will inform the development of a participatory, learning and action (PLA) informed group intervention, with a community linkage forum. The pilot of the PLA intervention will be evaluated using MRC process evaluation guidelines.

ETHICS AND DISSEMINATION

This project has received ethical approval from two sources. Universidad de Los Andes (2021-1393) and the University College London (16127/005). Dissemination of findings will include academic publications, community forums, policy briefs and visual media (cartoons, pod casts and short films).

Contributors are representative, as long as they agree: How confirmation logic overrides effort to achieve synthesis in applied health research

Introduction

The paradox of representation in public involvement in research is well recognized, whereby public contributors are seen as either too naïve to meaningfully contribute or too knowledgeable to represent ‘the average patient’. Given the underlying assumption that expertise undermines contributions made, more expert contributors who have significant experience in research can be a primary target of criticism. We conducted a secondary analysis of a case of expert involvement and a case of lived experience, to examine how representation was discussed in each.

Methods

We analysed a case of a Lived Experience Advisory Panel (LEAP) chosen for direct personal experience of a topic and a case of an expert Patient and Public Involvement (PPI) panel. Secondary analysis was of multiple qualitative data sources, including interviews with the LEAP contributors and researchers, Panel evaluation data and documentary analysis of researcher reports of Panel impacts. Analysis was undertaken collaboratively by the author team of contributors and researchers.

Results

Data both from interviews with researchers and reported observations by the Panel indicated that representation was a concern for researchers in both cases. Consistent with previous research, this challenge was deployed in response to contributors requesting changes to researcher plans. However, we also observed that when contributor input could be used to support research activity, it was described unequivocally as representative of ‘the patient view’. We describe this as researchers holding a confirmation logic. By contrast, contributor accounts enacted a synthesis logic, which emphasized multiplicity of viewpoints and active dialogue. These logics are incompatible in practice, with the confirmation logic constraining the potential for the synthesis logic to be achieved.

Conclusion

Researchers tend to enact a confirmation logic that seeks a monophonic patient voice to legitimize decisions. Contributors are therefore limited in their ability to realize a synthesis logic that would actively blend different types of knowledge. These different logics hold different implications regarding representation, with the synthesis logic emphasizing diversity and negotiation, as opposed to the current system in which ‘being representative' is a quality attributed to contributors by researchers.

Patient or Public Contribution

Patient contributors are study coauthors, partners in analysis and reporting.

Public Policy Responses to Address the Mental Health Consequences of the COVID-19 Pandemic: Evidence From Chile

Objectives: This paper reviews the mental health policies that have been implemented in Chile in response to the COVID-19 pandemic and the international context of countries' responses. Even before the start of the pandemic, there were significant barriers to access mental health services in Chile, coupled with a scenario of nationwide social unrest and protests that questioned the legitimacy of public institutions; now the rapidly worsening outbreaks of COVID-19 are exacerbating the pre-existing mental health crisis. Methods: We conducted a bibliometric and content analysis of the Chilean mental health public policies implemented during the COVID-19 pandemic and then compared these policies with international experiences and emerging scientific evidence on the mental health impact of pandemics. Results: Our analysis of the policies identifies five crucial points of action developed in Chile: (i) an established framework to address mental health in emergency and disaster situations; (ii) a timely COVID-19 Mental Health Action Plan; (iii) inclusion of mental health in the public health agenda; (iv) development of a presidential strategy during the pandemic for comprehensive mental health and well-being; and (v) emerging research assessing the mental health implications of COVID-19. Conclusions: In Chile, the public policy responses to address the mental health consequences of the COVID-19 pandemic has been characterized by the coordinated implementation of mental health plans, ranging from a health sectoral initiative to inter-agency and intersectoral efforts. However, it is imperative that increased funding is allocated to mental health, and efforts should be made to promote the participation of people with lived experiences and communities in the design and implementation of the proposed actions. This aspect could be of key importance to social peace and community recovery after the pandemic.

Communities, health-care organizations and the contingencies and contradictions of engagement: A case study from Chile

Context

Despite a growing interest in service‐user involvement in mental health services, the interaction between health institutions and local groups is only beginning to receive attention, particularly in global south settings.

Objective

Looking at a participatory initiative in Chile, this study explores how, under unfavourable administrative conditions, health organizations approach and work with communities.

Methods

We interviewed policy‐makers (5), local professionals (10), service users and community representatives (6) linked to a concrete participatory initiative. Participant observation in relevant meetings helped to enrich the interpretations. Thematic analysis was applied to interview transcripts and field notes.

Findings

The findings present a sequence of actions starting with the creation of a network of community‐based groups. A set of problems ensued, related to the group's diversity, internal representation, decision‐making and funding processes. In response, processionals implemented simultaneously bureaucratic and democratic adjustments, developing a vision of community that ignored the particularities—including the motivations—of local groups.

Discussion and conclusion

Based on these findings, we argue that participatory initiatives should be studied as on‐going achievements shaped by broad policy orientations and local configurations of interest. In the process, they produce ad hoc forms of knowledge and visions of community that provide orientation to the agents involved.

[Analysis of Governance in the Implementation of the Chilean Community Mental Health ModelAnálise da governança na implementação do modelo comunitário de saúde mental no Chile]

El presente artículo describe y analiza el rol que ha jugado la gobernanza en el desarrollo del modelo comunitario de salud mental en Chile. Se describen y analizan cinco dimensiones de la gobernanza: 1) el desarrollo de una serie de estrategias para favorecer la participación de los usuarios de servicios de salud mental ha logrado resultados insuficientes; 2) la implementación de tres planes nacionales de salud mental, que han mantenido la misma visión estratégica a lo largo de tres décadas, han contribuido a aumentar la accesibilidad a la atención comunitaria de las personas con enfermedades mentales y disminuir el rol de los hospitales psiquiátricos; 3) la inexistencia de una ley de salud mental persiste aún como un desafío, aunque haya sido parcialmente compensada por distintas leyes y decretos; 4) las regulaciones en la asignación de los recursos financieros, la formación del recurso humano y las directrices técnicas han contribuido a mejorar el acceso y la calidad de la atención; y 5) la construcción progresiva de un sistema de información en salud mental ha permitido conocer principalmente las tasas de acceso, las brechas de tratamiento y las inequidades geográficas. La experiencia chilena confirma la importancia de aplicar un conjunto de estrategias y mecanismos de gobernanza, para favorecer el desarrollo y el funcionamiento de los servicios de salud mental. El tipo de estrategias y mecanismos de gobernanza podrán variar en los distintos países según los contextos y las ventanas de oportunidades.

‘Are you a radical now?’ Reflecting on the situation of social research(ers) in the context of service-user activism in mental health

The relationship between activism and social research constitutes a longstanding source of debate. In the mental health and disability fields, this tension has specific connotations: User-survivor activism is premised on the priority of first-hand experience over detached, ‘objective’ knowledge. Personal experience is the foundation for the specific and irreplaceable perspective that users and survivors bring upon issues of interest. Considering this, how do user/survivor activist groups relate and collaborate with academically oriented researchers who lack a first-person encounter with psychiatry? Drawing on my participant observer role in a user-led activist group in Chile and through three ‘reflexive vignettes’, in this paper, I retrospectively trace how my interests and presence were received, negotiated and contested by users and non-users in the field. The findings describe three episodes in which my own status - and that of others participating ‘in the name of research’ - was interrogated. Although the group was open to anyone, boundaries emerged in response to specific demands from external agents interested in participating. A sense of ‘personal connection’ with the aims and nature of the group was one of those boundaries. In parallel, professional members had their own way of signalling their legitimacy, usually through a self-critical, anti-professional and anti-academic attitude. Doubts about my commitment to the group emerged as fieldwork progressed. The vignettes map the tensions that I experienced, the efforts I made to navigate them and the way they affected my disposition towards the group. The article argues that researcher’s reflexivity towards their own situation constitutes a primary source of information in the context of emergent, user-led advocacy efforts. Attention to how these groups accept and/or resist academic agendas provide insights into the solidarities and affinities that shape activist efforts. More than a pre-defined, ‘ethico-political’ disposition what’s required from researchers interested in this field is reflexivity to navigate the interface between academia and activism, honesty about the limits of academia and openness towards the contingent outcomes of an encounter with activism.

Beyond Participation: Politics, Incommensurability and the Emergence of Mental Health Service Users' Activism in Chile

Although the organisation of mental health service users and ex-users in Latin America is a recent and under-researched phenomenon, global calls for their involvement in policy have penetrated national agendas, shaping definitions and expectations about their role in mental health systems. In this context, how such groups react to these expectations and define their own goals, strategies and partnerships can reveal the specificity of the "user movement" in Chile and Latin America. This study draws on Jacques Rancière's theorisation of "police order" and "politics" to understand the emergence of users' collective identity and activism, highlighting the role of practices of disengagement and rejection. It is based on interviews and participant observation with a collective of users, ex-users and professionals in Chile. The findings show how the group's aims and self-understandings evolved through hesitations and reflexive engagements with the legal system, the mental health system, and wider society. The notion of a "politics of incommensurability" is proposed to thread together a reflexive rejection of external expectations and definitions and the development of a sense of being "outside" of the intelligibility of the mental health system and its frameworks of observation and proximity. This incommensurability problematises a technical definition of users' presence and influence and the generalisation of abstract parameters of engagement, calling for approaches that address how these groups constitute themselves meaningfully in specific situations.