5 MENTAL HEALTH POLICY ADVOCACY
Emma Wagner; Peyton Morey; and Doreen Danso
In this chapter we will learn about mental health promotion advocacy, the stakeholders involved, and the importance of policies that support mental health at community, national, and international levels.
5.1 KEY THEMES AND MAIN IDEAS
5.1.1 Introduction
Mental health promotion (MHP) advocacy involves initiatives that aim to raise awareness and promote policies and practices that foster mental health and well-being. Psychological well-being is a public health issue that should be addressed through policy interventions (Trudel-Fitzgerald et al., 2019; International Union for Health Promotion and Education, 2021). Advocacy efforts may involve working with policymakers, healthcare providers, educators, and community leaders to develop and implement effective MHP policies and programs (Jané-Llopis et al., 2011). Effective advocacy may include educating stakeholders about the benefits of MHP, promoting collaboration and partnerships, and engaging the public in discussions about mental health (Weist et al., 2003). MHP advocacy plays a critical role in reducing the stigma surrounding mental illness and promoting mental health as an essential aspect of overall health and well-being (Min et al., 2013; Sturgeon, 2006). This section aims to determine the efficacy of the current MHP measures implemented in varies settings and populations. This includes schools, workplaces, healthcare facilities, as well as within government policies. Furthermore, the importance of nation and international policy making, and diversifying research methodology and evidence-based programming in all aspects of MHP will be covered.
5.1.2 The Importance of Health Promotion Policy Interventions in Promoting Well-Being
The promotion of well-being is an essential aspect of overall public health. Workplace mental health programs, accessible mental health care, and school-based mental health initiatives are crucial interventions that can prevent adverse health outcomes associated with mental illness (Trudel Fitzgerald et al., 2019). Traditional approaches to mental health, especially among high-risk groups, have primarily focused on treatment. Treatment-only approaches are reactive in nature, meaning they do not take early preventing steps to reduce risk or protect against mental ill health and are thus, inadequate in preventing poor mental health. Prevention efforts, especially early prevention efforts, which aim to target known-risk factors of mental illness, take proactive steps to prevent mental ill-health and require more attention in programming and policy (Min et al., 2013). Mental health policies and interventions that focus on prevention and early intervention can reduce the burden of mental illness in individuals, particularly children and adolescents (Min et al., 2013; Shatkin & Belfer, 2004). providing support and resources to these groups, the incidence of mental ill health may be reduced, and their overall well-being improved (Min et al., 2013; Shatkin & Belfer, 2004).
Policies that address the social determinants of mental health can have significant impacts on public health. MHP policies can address social determinants that impact mental health, such as poverty, inequality, and discrimination (Min et al., 2013; Sturgeon, 2006). These policies may involve investing in community programs that provide access to mental health resources, improving access to affordable housing, and reducing stigma around mental health (Min et al., 2013; Sturgeon, 2006). One way to achieve this is through early interventions and prevention programs that target high-risk groups, such as children and adolescents, who may be more susceptible to developing mental illness (Min et al., 2013; Shatkin & Belfer, 2004). Shatkin and Belfer (2004) argue that the absence of mental health policy for children and adolescents is a significant global issue. Min et al. (2013) highlights the importance of MHP and illness prevention as a crucial aspect of public health.
Empirical research demonstrates that mental health and mental illness are separate concepts, which can, but do not always coincide (Keyes, 2002). Individuals who have mental ill health are at increased risk of mental illness, while flourishing (i.e., positive mental health) protects against mental illness, but also improves day-to-day functioning and overall well-being (Keyes, 2005). The dual benefit of promoting positive mental health (i.e., risk-reduction and mental health promotion) demonstrates that promotion and prevention efforts need not be separated, and that policies and interventions focusing on the promotion of mental health may encompass and extend beyond those with a sole prevention focus and/or target beyond at-risk populations (Barry, 2001; Barry, 2007). Therefore, a shift is necessary, with policies and interventions which emphasize mental health promotion where relevant, and supplement with preventive approaches in at-risk or treatment-typical populations (Keyes, 2007). As such, positive mental health promotion should be a critical component of overall health promotion policies. Further research is needed to identify policy-level factors most relevant to mental health status, to inform effective intervention in policy and practice (Enns et al., 2016; Keyes, 2010; Trudel-Fitzgerald et al., 2019).
5.1.3 The Role of Public Health in Addressing Mental Health Promotion
MHP has become an increasingly important aspect of public health, as the disparities associated with of mental ill health continue to rise globally. Evidence-based policies and interventions can play an important role in promoting psychological well-being and preventing mental ill health (Jané-Llopis et al., 2011). Public health professionals have the expertise to develop and implement these policies and interventions, which can include strategies regarding awareness and knowledge translation campaigns (e.g., Bell Let’s Talk), intervention programs, and policies that support healthy schools, workplaces, and target communities (International Union for Health Promotion and Education, 2021; Jané-Llopis et al., 2011). Experts can also work with stakeholders across different sectors, such as healthcare, education, and social services, to develop coordinated approaches to MHP (Jané-Llopis et al., 2011). For example, the MENTUPP Intervention study by Arensman et al (2022) showcases the important role of public health in addressing psychological well-being through policy change. The MENTUPP Intervention study is a comprehensive program aimed at promoting mental health and well-being in the workplace (Arensman et al., 2022). The program is multifaceted, and it includes interventions targeted at both individual and organizational levels. At the individual level, the program offers stress management and communication skills training to employees (Arensman et al., 2022). These interventions are designed to equip employees with the tools they need to manage stress, communicate effectively, and build on self-efficacy skills, which can ultimately contribute to their overall mental health and well-being (Arensman et al., 2022). At the organizational level, the MENTUPP Intervention program focuses on changes to the work environment and culture (Arensman et al., 2022). The program promotes a work environment that is supportive of mental health and well-being. This includes creating policies that address mental health, such as flexible working hours, and promoting a culture of openness and support around mental health issues (Arensman et al., 2022). By targeting both individual and organizational factors, the MENTUPP Intervention program creates a comprehensive approach to MHP in the workplace. This study exemplifies the role of public health in addressing psychological well-being through policy change.
5.1.4 Mental Health Improves Through the Integration of Healthy Public Policies
Importance of Developing Mental Health Policies at the National and International Levels. Mental health policies are critical to promoting mental well-being and reducing the stigma surrounding mental illness (Sturgeon, 2006). National policies can help raise awareness and ensure that mental health services and resources are accessible to all individuals, while international policies can promote collaboration and knowledge translation across countries (Sturgeon, 2006). Evidence-based research is crucial to policy development, and national and international contributions can aid in addressing global disparities in mental health policies (Jané-Llopis et al.,2011). The following section highlights the importance of developing mental health policies at both the national and international levels.
The importance of national and international policies in addressing mental ill health cannot be overstated. A review conducted by Sturgeon et al. (2006) highlights the need for policy implementation to raise awareness of mental health issues and reduce the stigma associated with mental ill health. Specifically, policies can help ensure that mental health services and resources are available to all, irrespective of their socioeconomic status or geographical location. The integration of mental health services into primary care and other health services is an essential aspect of national policies by promoting a holistic approach to healthcare and emphasizing the importance of treating the whole person rather than merely addressing physical ailments. By incorporating mental health into primary care, patients are more likely to receive timely and comprehensive care for their mental health needs (Sturgeon, 2006). Policy-level interventions may be more effective than individual-level interventions in promoting mental health and preventing mental illness in this population (Conley et al., 2013). At the national level, policies can be developed to promote mental health and prevent mental illness in higher education settings. These policies included initiatives such as providing mental health services on campus, promoting mental health education and awareness programs, and creating supportive environments for students while addressing distressing issues such as student debt, housing insecurity, and food insecurity (Conley et al., 2013). Sturgeon et al (2006) further argue the importance of international policies in promoting knowledge translation and understanding of mental health issues across borders and countries. These policies can help develop cooperation and collaboration between countries, which can facilitate the sharing of best practices and resources for the funding of mental health programs and services (Sturgeon, 2006). By prioritizing mental health on a global scale, international policies can help ensure that resources are allocated to address mental health issues, particularly in low- and middle-income countries as well as other target populations such as post-secondary students (Conley et al., 2013; Sturgeon, 2006).
5.1.5 Mental Health Promotion through Education and Prevention Programs
MHP through education and prevention programs has been recognized as an effective strategy for improving mental health outcomes by helping individuals develop skills and coping mechanisms to deal with stress and adversity, prevent the onset of mental ill health, and reduce the negative impacts of mental ill health issues on individuals and their communities (Sabiston et al., 2020). Researchers have evaluated the effectiveness of these programs in various settings, such as schools, communities, and workplaces, and have demonstrated their potential to improve mental health outcomes. For example, McMorris et al. (2005) evaluated the effectiveness of a universal school-based prevention program for reducing depressive symptoms and substance use among adolescents using a randomized control trial. The program consisted of group sessions that focused on developing social capacities, decision making skills, and coping strategies; students who participated in the intervention program reported significantly lower levels of depressive symptoms and substance use compared to the control group (McMorris et al., 2004). Specifically, students who participated in the program had a 12% reduction in depressive symptoms and a 10% reduction in substance use compared to the control group, which was maintained six months after the program had ended (McMorris et al., 2004).
Programs and interventions aimed at promoting mental health are not limited to school-based settings. Workplace settings have also been the focus of research investigating the efficacy of MHP initiatives. The MENTUPP project previously covered is an example of the interventions currently in the process of implementation and assessment (Arensman et al., 2022). While it is widely known that workplace settings foster mental ill health, less than 10% of MHP programs are designed specifically with this demographic in mind (Arensman et al., 2022). The anticipated results of this study support the importance of MHP through education and prevention programs in the workplace (Arensman et al., 2022). By providing mental health education, training, and implementing policies that promote mental health and reduce stigma, workplaces can help to improve the mental health and wellbeing of their employees (Arensman et al., 2022).
5.1.6 Collaborative Approaches are Critical in Advocating for Mental Health Promotion Interventions and Policy
Stakeholder Engagement in the Development and Implementation of Mental Health Promotion Policies and Programs. Mental health is an issue that affects everyone, and therefore, stakeholders must be involved in the process of developing and implementing policies and programs that address mental health issues. Stakeholders in MHP policies and programs include individuals with lived experience of mental illness, mental health professionals, policymakers, researchers, community organizations, advocacy groups, and other interested parties (Trudel Fitzgerald et al., 2019). The involvement of these stakeholders ensures that the policies and programs are tailored to the needs of the community and that they are more likely to be effective (Trudel-Fitzgerald et al., 2019). Stakeholder engagement can help to identify the most pressing mental health issues in a given community and can help to develop strategies to address these issues. For example, in a framework developed by Mantoura et al (2014) described five elements in developing mental health policies. One of these elements involves building partnerships and networks among stakeholders from various sectors, including government, non-governmental organizations, educators, and community-based organizations (Mantoura et al., 2014). As described by Weist et al (2003), “Stakeholder involvement in planning and implementation can promote increased ownership, support, and sustainability of programs” (p. 74). Stakeholders are also pertinent in bridging the gap and building trust between the community and policymakers (Weist et al., 2003). When stakeholders are involved in the development and implementation of policies and programs, they are more likely to be supportive of these initiatives and to advocate for their success (Weist et al., 2003). This can help to build momentum and support for MHP policies and programs, leading to greater investment and better outcomes (Weist et al., 2003).
Collaboration with Youth in Decision Making and Policy Research. Engaging youth in decision-making processes and research on policies that affect their mental health can lead to more effective and relevant strategies for promoting mental health and preventing mental ill health (Shatkin & Belfer, 2004). Youth and young adults are among the most at risk for developing mental health challenges (Jenkins et al., 2020; McMorris et al., 2004; Min et al., 2013; Shatkin & Belfer, 2004). In low and middle-income countries, up to 80% of children with mental disorders do not receive the proper care, even though it is estimated that 10%–20% of children and adolescents worldwide have one or more mental disorders (Kieling et al., 2011).
By involving young people in the development, implementation, and evaluation of mental health policies and programs, we can better understand their needs and experiences, and design interventions that are more responsive and effective (Shatkin & Belfer, 2004). The importance of collaborating with youth in mental health policy research is explored using a variety of strategies and theories.
One such program is the Agenda Gap Intervention designed by Jenkins et al. 2020) and evaluated recently (Jenkins et al., 2023). The Agenda Gap intervention seeks to bridge the gap between research evidence on youth MHP and current policies and practices (Jenkins et al., 2020). The intervention consists of a series of workshops and other activities designed to engage policymakers, researchers, and youth advocates in the development and implementation of youth mental health policies (Jenkins et al., 2020). This study emphasizes the importance of involving youth in mental health policy decision-making processes as they are the ones who are directly affected by these policies (Jenkins et al., 2020).
Moreover, the study reported that the Agenda Gap Intervention led to changes in policy and practice, with participating policymakers indicating a greater willingness to work collaboratively with youth advocates and researchers in the development and implementation of mental health policies (Jenkins et al., 2020). The Agenda Gap project resulted in increased advocacy and leadership skills among youth advocates who participated in the intervention (Jenkins et al., 2020).
Another theoretical framework that has been developed with the mental health of youth and adolescents in mind is the social and emotional learning framework (SEL). In a conceptual review, Payton et al. (2000) reveal the efficacy of collaboration between educators, mental health professionals, policymakers, and community members in promoting positive social and emotional development in young people (Payton et al., 2000). This framework highlights the importance of involving youth in the development and implementation of mental health policies (Payton et al., 2000). Additionally, involving youth in the implementation of mental health policies can help to promote greater buy-in and support from young people, which can improve the effectiveness of the policies (Payton et al., 2000).
5.1.7 Conclusion
While this chapter highlights the importance of MHP and the efficacy of current measures, there is still a need for future research to better understand the effectiveness of MHP in diverse settings and populations. Although progress has been made in reducing the stigma surrounding mental health and promoting mental health as an essential aspect of overall health and well-being, much work remains to be done. There is a need for continued advocacy efforts to promote mental health policies and programs, and for further collaboration among stakeholders, including policymakers, healthcare providers, educators, and community leaders. Future research should aim to develop evidence-based MHP strategies that can be tailored to meet the unique needs of different populations and settings. By continuing to prioritize MHP, we can improve the well-being of individuals and communities and promote a more equitable and healthy society.
Mental Health Policy Advocacy increases awareness and promotes positive mental health to decrease stigma. Mental health policies must be established across multiple settings- school, work, community, and public health with early intervention and prevention programs.
5.2 GAPS AND LIMITATIONS
In this section we will uncover the limitations in existing mental health policy, such as a lack of clear foundation to determine the relationship between policy and psychological well-being, and lack of generalizability from current sampling methods.
5.2.1 Introduction
Public policy is a major arena to apply a MHP lens. The goal of mental health policies is to eliminate the risk factors that can contribute to poor mental health and make it easier for people to live in ways that are good for their mental health . Policy interventions can focus on critical issues that affect mental health at the individual, societal, structural, and environmental levels (Mantoura, 2014). For example, the mental health consequences of the global pandemic (especially among young people, people of colour, and people who already have mental health problems; Mantoura, 2014) highlighted the need for improved and reimagined ways to reach those who need support the most (e.g., telehealth). In general, MHP programs have been very important in reducing the consequences of the pandemic on mental health (Rickwood, 2011). This section will describe how public policies affect mental health through the significance of systems, organizations, and institutions, as well as the risk and protective factors for good mental health, and how important it is to recognize upstream influences on mental health outcomes.
5.2.2 How mental health is affected by society
Systems, organizations, and institutions are very important for improving mental health and well-being (Hameed et al., 2020) by providing access to services, resources, and support networks for mental health promotion. Institutions such as schools can use policies and programs to improve individual’s mental health and help prevent mental health problems from developing (Hameed, Mehrotra, & Murthy, 2020). Positive youth development initiatives on college campuses, for example, have been found to improve mental health and lower mental distress (Hameed, Mehrotra, & Murthy, 2020). Each socio-ecological domain has risk and protective variables for positive mental health (Kuhlberg, Pea, & Zayas, 2019). At the individual level, risk factors for poor mental health are based on genes, personality traits, and previous trauma. Protective variables include strong social support networks, healthy ways to deal with stress, and positive psychological attributes like resilience and self-efficacy (Kuhlberg, Pea, & Zayas, 2019). Environmental variables like poverty, discrimination, and social isolation can also raise the likelihood of poor mental health (Kuhlberg et al., 2019). On the other hand, settings that are supportive and caring can help improve mental health.
5.2.3 A policy that is good for the public and mental health
Recognizing “upstream” influences on mental health outcomes is crucial because it makes it possible to take a more complete approach to promote and preventing mental health problems (Rickwood, 2011). Implementing policies and programs that address individual, community, and societal variables is one way to address mental health risk and protective factors across different socio-ecological domains (Siddiqui et al., 2019). For example, mental health programs in schools can help kids and teens learn about mental health and teach them how to deal with problems, while mental health programs in the workplace can help people deal with stress and find a good balance between work and life. Community-based programs that address social determinants of health, such as access to affordable housing and transportation, can help improve mental health. (Siddiqui, Feinberg, & Stein, 2019).
Policy goals for mental health
Kuhlberg and colleagues (2019) state that some priorities for mental health policy include promoting positive childhood development through early childhood education and support for parents, creating healthy workplaces that put the mental health of employees first, giving communities the power to deal with social determinants of health, providing positive and easy-to-access mental health services, and reducing the stigma around mental illness.
The literature has sparse evidence on the link between implementing mental health-promoting policy and psychological well-being; more research is needed to build clear understanding on the policy impact for mental health outcomes (Siddiqui, Feinberg, & Stein, 2019). Small sample sizes for quantitative studies make it hard to apply the results to other populations, especially in low- and middle-income nations, and call for more rigorous methods. Existing research has found that some aspects of psychological well-being are linked to lower risks of premature death from all causes (Siddiqui, Feinberg, & Stein, 2019). For effective interventions that can deal with the diverse effects of mental health policy, it is important to involve and work with target communities, especially marginalized groups (Siddiqui, Feinberg, & Stein, 2019).
Future research should focus on developing a clear framework for making and evaluating mental health policies that are based on evidence and take into account the various needs of different groups. Even while the summaries stress how important it is to engage and work with target audiences, they don’t give concrete suggestions for how to engage and work with these populations effectively. Future research should focus on finding the best ways to involve and work with target groups to make sure that mental health policy initiatives work and are fair for everyone.
5.2.4 Conclusion
Mental health can be promoted through healthy public policies, but the development and evaluation of policy need to follow the best practices for mental health promotion which remains underdeveloped). Future research on mental health policy should focus on finding effective policies and interventions that address mental health on several socio-ecological levels such as how well policies and programs are put into place in varying settings. Kuhlberg, Pea, and Zayas (2019) say that research should also focus on making and evaluating interventions that are culturally and linguistically acceptable for different communities. Mental health policy needs better evidence and an evaluation framework to develop the best practices to support mental health, through the use of larger sample studies across many different sociodemographic groups.
5.3 FUTURE RESEARCH DIRECTIONS
This section will study how the gaps in current mental health policy can be addressed with future research, such as improving research methods to study the mental health of all individuals.
5.3.1 Introduction
There are currently many gaps in MHP policy and advocacy that can be filled with the help of future research. The purpose of this section of mental health policy and advocacy is to find ways to adapt research to fill the present gaps and limitations in previous research. MHP is a growing field and therefore has many avenues for future research (Mantoura, 2014). Research can be expanded in sample diversity and methodological advances. Future research should be performed on populations of lower income, marginalized communities, and youth. Future methods in research should include testing causal relationships and use varying types of study designs that fit the program or policy under study. Finally, future research should aim to have impacts be more sustainable in populations by creating findings that are accessible, personable, and monitored.
5.3.2 Diverse populations
Socio-ecological considerations
A major area for improvement in future research is for more diverse population samples that look at people in higher need of mental health support. Communities of lower income and socioeconomic status are disproportionately affected by mental illness, therefore increased advocacy and adapted policy research are important (Saraceno et al., 2007). Bronfenbrenner’s theoretical framework (the socio-ecological model; see Chapter 1) looks at the influence of social environments on human development and can be used as a guide for policy development at different levels of influence. Applying this framework to the development of policies also has a positive effect by addressing all areas of human systems. Incorporating advocacy at all these levels has been supported by research that places the individual at the center of design (Marshall-Lee et al., 2019).
Population-specific methodologies
Those who have been historically marginalized face unique struggles compared to other people; research should be adopted for specific demographic groups (e.g., culture, sex, socio-economic status) is needed for the adoption of policies to be successful. For example, Delva et al. (2013) found that depression, anxiety, and fear in those affected by immigration policies and undocumented are a result of current national immigration policies. Future research should incorporate the lived experience of people and apply socio-ecological models of policy to provide applicable policy and advocacy. Current generalized models of mental health policy are far too “one size fits all” to support this population of individuals in the way they need. To ensure this is done properly, autonomy needs to be sustained by allowing these communities to use their voice, advocate for themselves, and not have others speak on their behalf (Ridley et al., 2018). Youth mental health policy can be improved in future research by increasing communication with the population to address concerns and needs (Shatkin & Belfer, 2004). Placing policies in school are also a great way of connecting with youth in the microsystem that has a direct effect on development (2021).
5.3.3 More Sophisticated Research Design and Methodology
Future research should develop more rigorous methodology to improve the quality of research and its findings. For strong research to be adapted for future studies, measured outcomes should be clearly defined in the settings of the study. This will allow for research to identify causal relationships while also creating more applicable findings. Understanding the long-term effects policies have on mental health is one of the most important aspects that are lacking in current research. Examining the link between cause and effect in future research will allow researchers to find areas of policy and advocacy that did not work, thereby allowing for improvements and adaptation (Mantoura, 2014).
Sustainability
Efforts to help policy and advocacy resulting from research to be sustainable is needed. For research impact to become sustainable in populations, future research needs to conduct ways of producing accessible and applicable policies. Newbigging et al. (2015) found that the accessibility and sustainability of policies are increased when users’ perspectives (i.e., lived experience) are considered during the creation of programs and use of these programs. Measuring well-being can address personal gaps in current resources which can then be addressed to improve engagement (Alter et al., 2019). Future research should be followed by extensive ongoing monitoring to identify areas of improvement and success for future applications to be more successful and sustainable. Hann’s et al. (2015) research in Sierra Leone was able to show how insufficient long-term resources and support results in poor mental health care resources and advocacy. This can be better supported in future research performing varied kinds of research such as longitudinal studies.
5.3.4 Conclusion
Mental health policy is essential in all policies to ensure the mental well-being of all people. Mental well-being and its promotion are the roots of creating people who benefit society the most. Current gaps in literature and policy need to be addressed to improve future policies and their success. Improving research in the field of mental health policy and advocacy will result in more effective and applicable research for communities in need of mental health support. Populations of lower income, marginalized communities, and youth are at risk of higher mental illness therefore a larger amount of research should be done in these communities to have higher rates of success. Using a bio/socio ecological framework in this research is important for addressing a more diverse population of people. Future research should include methods that are clearly defined, use cause-effect relationships, and use varying types of study designs. Sustainable research findings that are needed in the future will be done by studies being accessible, personable, and monitored.
Mental health policies can continue to blossom with future efforts in studying diverse and marginalized populations, including the perspectives from members of the community, and supporting all levels of the Socio-Ecological model.