Mental Health from a Public Health Lens
It’s Children’s Mental Health Acceptance Week! It is meant to spur us beyond passive awareness and into action! That action needs to be guided by the principles that inform best practices to be effective.
I have been thinking about mental health models from a public health lens. Public health tries to provide support as early as possible to prevent illness, and when that is not possible, to help people live lives of meaning anyway. It is often represented by a triangle like the one below, with the bottom of the triangle being the earliest supports provided at a universal level/tier, for everyone in a population without any identification of ill health or risk. In childhood, these are whole school mental health promotion programs such as social and emotional learning (SEL; see CASEL), or Every Moment Counts that teach all children basic mental health skills and embed practice of these in the school day to help increase the general mental health and happiness of everyone. While it is harder to reach all adults, this might be providing education on positive psychology practices such as mindfulness or kindness to everyone in a population, perhaps through an activity like a morning yoga session at a work conference to help attendees begin the day refreshed and ready to learn. These universal interventions don’t seek to identify any kind of illness or problem, but they do try to prevent issues by building positive mental health in everyone.
Figure 1: Public health triangle across the lifespan with practices consistent with Wraparound/Systems of Care in childhood and Recovery in adulthood. In the segmented center triangle are the principles of wraparound on the left, recovery on the right, and shared principles in the center. They are roughly situated in the tier where they begin to guide practice, beginning from tier 1/universal at the base, to tier 2/targeted at the middle, and tier 3 at the top. Practices at lower levels continue to apply to higher levels. Potential interventions and activities congruent with Wraparound/SoC principles are featured at universal, targeted, intensive levels are featured on the left. Potential interventions and activities congruent with Recovery principles are featured at universal, targeted, intensive levels are featured on the right. Wraparound Principles (Dennis & Lourie, 2006): Recovery Principles (SAMHSA, 2012).
Abbreviation Keys: Child - IEP/Individualized Education Plan, EMC/Every Moment Counts Adult - CCBHC/Certified Community Behavioral Health Clinic, RAS-DS/Recovery Assessment Scale - Domains & Stages, NEW-R - Nutrition and Exercise for Wellness & Recovery
A public health approach assumes that providing support to everyone will help everyone be more resilient so that when they face adversity, they are more likely to be able to bounce back. The second or targeted level/tier of this model tries to identify people who have encountered risk factors and looks to providing them some extra support, still without necessarily labeling them as having a condition indicating mental ill health. Children may be at risk due to things like learning disabilities, a history of trauma, stigma or bullying. Universal interventions are still important here, but we add small group interventions, supports like peer mentors, and helping individuals and people around them to develop strategies to cope effectively with trauma responses. Small group interventions might do things like identify strengths and encourage activities to broaden those, or perhaps facilitating restorative circles to manage conflict better.
The main idea behind a public health approach is that if people are in groups and communities that receive robust supports at the first two tiers, fewer will develop the symptoms that warrant diagnoses and require intensive tier three intervention. This is important because outcomes are better when people can avoid significant behavioral and mental disorders. That said, there are best practices that increase the likelihood of good outcomes even at this level of need. These are practices and supports such as wraparound for children and youth, and recovery for adults. The center of the first figure, looks at the intersectionality of the principles of wraparound and of recovery which ground best practices in mental health across the lifespan.
Occupational Therapy across Populations, Groups and Persons
* Multi-Tiered Systems of Support is the term used to apply to the use of the public health model in school settings.
The public health model applies across all disciplines working in mental health. Because I am an occupational therapist, it has been important to look at the Occupational Therapy Practice Framework (OTPF) in the context of the public health model. While the OTPF uses the terms populations, groups and persons, those fit neatly into the universal, targeted and intensive tiers of the public health framework as pictured in Figure 2. What is unique to occupational therapy is our focus on helping people engage in the occupations (social participation, activities of daily living/ADLs, independent activities of daily living, sleep/rest, play/leisure, work, health management) that they need and want to do while at the same time using occupation as therapy. This all just means we have a focus on function and doing both in therapy and as the ultimate outcome for the people, groups and populations we serve.