The WHO “Guidance on community mental health services: promoting person-centred and rights-based approaches”, released in June 2021, provides examples of community-based mental health care that is both respectful of human rights and focused
on recovery.
Here are some examples.
Community outreach services
Atmiyata, India
Atmiyata is a community volunteer service that identifies and supports people experiencing distress in rural communities of Gujarat state in western India.
The Gujarat branch of Atmiyata was established in 2017 in the Mehsana district of Gujarat state, home to 1.52 million people and 645 villages, following a successful pilot project in 41 villages of Maharashtra State in 2013-2015.
Volunteers have the following roles: to raise awareness in the community about mental health issues; to identify individuals experiencing distress and provide 4-6 sessions of counselling; to refer people who may have a severe mental health condition to the public mental health service; and to support people in need with access to social care benefits.
Atmiyata Gujarat was evaluated in 2017 over a period of eight months using a stepped wedge cluster randomized controlled trial. Results showed that recovery rates for people experiencing distress were clinically and statistically higher in people receiving
support from the Atmiyata service compared with the control. Improvements in depression, anxiety, and overall symptoms of mental distress were seen after three and eight months. Significant improvements in functioning, social participation and quality
of life were reported at the end of eight months.
Atmiyata Gujarat was initially funded by Grand Challenges Canada but now receives support from Mariwala Health Initiative, in partnership with Altruist, a local non-governmental organization funded by the Government of Gujarat and TRIMBOS Institute.
Credit: Amiyata, Gujarat
Community-based mental health centres
CAPS, Brazil
In Brazil, community-based mental health centres are known as Centro de Atenção Psicosocial (CAPS). They are the cornerstone of the community-based mental health network and are well integrated at the primary care level. CAPS III services cater for adults as well as children and adolescents and provide 24-hour service in areas with a population greater than 150 000.
CAPS III Brasilândia operates 24 hours a day, seven days a week. The service is managed by the social organization, Family Health Association (Associação Saúde da Família). Like all CAPS III services, the centre provides continuous, tailored community-based mental health care and support, including crisis services.
CAPS III Brasilândia is designed to create a structure and environment similar to that of a home. Structurally, the centre has indoor and outdoor common areas for socializing and interacting with others, a dining area, individual counselling rooms, a group activities room, pharmacy, and female and male dorms, each with four beds, where people who are in crisis or need respite can stay for up to 14 days. The centre also holds activities and events in the community using public spaces such as parks, community leisure centres and museums.
A 2020 evaluation of CAPS III Brasilândia found that the services offered are consistent with a human rights and recovery-oriented approach. The Centre has also been assessed using the World Health Organization’s QualityRights assessment toolkit and was evaluated as fully compliant with all WHO key standards, including the physical and social environment of the service, quality of care, respect for informed consent to admission and treatment, non-use of coercive practices and the promotion of community inclusion for people using the service.
CAPS services are delivered and funded under the Unified Health System of Brazil with no cost to users. Operational costs (50-70% of total cost of service) are covered by the federal government with the remainder provided by the municipality.
Credit: CAPS, Brazil
The Aung Clinic is a community-based mental health service located in Yangon, Myanmar. The Clinic provides emergency drop-in services to long-term therapy and offers an extensive range of support activities for people with mental health conditions and
psychosocial disabilities. The service supports over 200 individuals and their families per year and is the only service of its kind in the country.
The Aung Clinic receives people experiencing a range of mental health conditions, such as depression, bipolar disorder, post-traumatic stress disorder, psychosis and substance use disorders. The Clinic is open daily for treatment and provides outreach
services to individuals and their families, with follow-up by telephone and online support if needed. Emergencies are responded to outside of regular hours and on weekends.
People are welcome to attend during the day, including those who are homeless, but there are no overnight stays. By spending daytime hours at the clinic, people in crisis are often able to avoid hospitalization.
The Clinic conducts assessment and offers individual counselling, group therapy, medication, vocational skills training and peer support groups for service users and their families. Talk therapy, family therapy and mindfulness are all used. The Clinic
also advocates for the rights of people with mental health conditions and psychosocial disabilities, working closely with schools, employers, and local organizations.
An unpublished 2020 qualitative evaluation of 20 people visiting the Clinic indicated positive results. The art therapy and group therapy sessions were seen to be particularly valuable. Service users spoke of finding acceptance at the Clinic and feeling
more able to manage mental health conditions since attending.
The Aung Clinic is a non-profit service; its services are provided free to users. It opened in 2010 without external funding and has expanded in recent years with funding from the Open Society Foundations.
Credit: Aung Clinic, Myanmar
Crisis services
Tupu Ake, New Zealand.
Tupu Ake is a peer-led, crisis admission service located in Papatoetoe, a suburb of South Auckland, offering short stays and a day support programme.
Tupu Ake was established as a pilot recovery house service in 2008 by the nongovernmental organization, Pathways Health, a national provider of community-based mental health services and one of the first mental health services in New Zealand to provide an alternative to hospital admission. Serving a region of 512 000 people, Tupu Ake offers short stays of up to one week for a maximum of 10 people, and a day support programme for up to five people.
An independent evaluation was conducted in 2017 based on qualitative interviews with service users and other stakeholders including staff from Tupu Ake, Pathways and the District Health Board. The results showed people using the service experienced positive outcomes in terms of levels of self-determination and an increased ability to cope with their experiences. Guests reported higher levels of satisfaction with care and shorter average lengths of stay at Tupu Ake than hospital inpatient units. The evaluation highlighted the positive role Tupu Ake played in repairing relationships with family and social networks, and the welcoming environment provided by the villa and grounds.
Tupu Ake is free of charge to individuals using the service as it is fully funded by New Zealand’s public health system.
Credit: Wise Management Services Ltd, courtesy of Tupu Ake
Hospital-based services
BET Unit, Norway
Previously part of the locked psychosis unit at Blakstad Hospital, a large urban psychiatric hospital in Asker, Norway, in 2018, the BET Unit became an independent open-door service available 24 hours a day, seven days a week. The unit is equipped with
six beds and provides treatment and support to an average of 6-10 people per month. The service has nearly 20 employees, including a psychiatrist and two psychologists. Treatment includes group and individual sessions and physical activity. Most
individuals living close by go home every weekend.
Typically, people referred to the BET Unit – by general practitioners, outpatient clinics and inpatient wards from other hospitals – have previously experienced numerous or lengthy intensive inpatient admissions, without improvement. Many
have received multiple diagnoses, from psychosis to personality disorders, have had a substance use disorder, have repeatedly self-harmed or attempted suicide, have used multiple psychotropic drugs for prolonged periods of time, or have been subject
to coercive interventions in mental health services.
The BET concept invites individuals to acknowledge and accept frightening thoughts and feelings, and manage them with more functional coping strategies, rather than relying on avoidance strategies such as self-harm, inactivity and hyperactivity, starvation
and overeating, dissociation, and harmful use of legal and illegal drugs.
A 2017 study found that individuals who used the service had fewer admissions to psychiatric and general hospitals in the 12-month period after discharge from BET, compared with the 12-month period before admission. One qualitative study of users of the
BET Unit found that participants displayed fewer symptoms of mental health conditions, a significantly improved level of functioning and had re-established connections with their families. Some had restarted education or returned to work. Some had
stopped using medication altogether.
The BET service has been publicly funded for 20 years as part of the public health care system.
Peer support services
Users and Survivors of Psychiatry, Kenya
Users and Survivors of Psychiatry in Kenya (USP-K) promotes and advocates for the rights of persons with psychosocial disabilities through peer support to its members and training on self-advocacy and human rights.
Since its inception in 2012, USP-K peer support groups have expanded to 13 groups in six counties across Kenya.
As an example, the Nairobi Mind Empowerment Peer Support Group brings together individuals with lived experience of mental health conditions or psychosocial disabilities.
The group supports people in becoming autonomous in their decision-making and day-to-day lives by helping people to think through and make decisions about their employment situation, living arrangements and health care and treatment. The group also helps members access social and disability benefits and economic empowerment programmes. It supports them through mental health crises and helps them plan for potential future crises in a way that ensures that the use of coercive measures or practices are avoided.
Independent qualitative research on the USP-K Nairobi Mind Empowerment Peer Support Group involved observations of peer support group meetings, focus group discussions and interviews with carers and USP-K staff. The study found that the peer support groups and members specifically promoted members’ agency and autonomy.
The USP-K umbrella organization provides initial seed funding for new groups for the first two to three years.
Supported Living Services
KeyRing, United Kingdom of Great Britain and Northern Ireland
KeyRing was established in 1990 to provide time-limited independent but supported living arrangements for people experiencing mental health conditions. Today KeyRing has more than a hundred networks in about 50 local authority areas across England and
Wales. Networks of support consist of 10 or more ordinary homes located within walking distance of each other. Housing is either rented from local authorities or housing associations or owned by members.
Each network ensures that KeyRing members take control and responsibility over their lives by living in a place of their own, as well as contributing and being connected to their local community.
Community volunteers live in KeyRing accommodations within the network location and provide support to members with day-to-day activities, such as managing bills and budgeting and accompanying them to appointments for education and employment. Community Connections Volunteers share their knowledge and skills and with network members.
Since the first evaluation in 1998, KeyRing has consistently received positive reviews of the quality of its service and its cost-effectiveness. A 2018 evaluation by the Housing Learning and Improvement Network concluded that each year the presence of
the KeyRing networks led to: 30% of members avoiding a psychiatric inpatient admission; 30% fewer cases of homelessness; 25% of members no longer requiring weekly visits from community psychiatric nurses or social workers/care coordinators;
and 20% of members no longer requiring weekly drug/substance misuse worker visits.
The service is funded by the social care budget of UK local authorities, which is allocated by the central government. Since cuts to central government funding in 2010, other sources of funding have been sought to finance the service. People using the service also contribute, if their income is above a certain threshold.
Credit: Sean Kelly for KeyRing Living Support Networks