RESEARCH REVIEW (NS) VOL. 13, NOS, 1 & 2 (1997) TOWARDS A HOLISTIC APPROACH TO FAMILY MENTAL HEALTH IN AFRICA Kwaku Osei-Hwedie Introduction The subject of family mental health requires a more holistic and synthesizing approach to development and issues associated with sustainability. This is because families reflect the strengths and weaknesses of the socio-economic and developmental welfare environment Thus, the family must be the first basic consideration in favour of an integrated approach to social progress and welfare in the context of mental health. Despite the changing nature of families, it is becoming increasingly clear that the family, as a basic unit of society, must play major roles in resolving social problems. Many governments are pushing more and more responsibilities to families. In addition, teachers, social workers, health and other practitioners routinely look upon the family as part of the resource or solution to the problems they deal with. The embracing of de-institutionalization and community based approaches to social service provision also facilitate the trend to give more responsibilities to the family. However, families are not always ready or able to effectively cany out these responsibilities, hi many cases, they are not sufficiently empowered to be effective. Hence the abilities of families to sustain respectable living standards are at times problematic. Ink this regard, main- taining a healthy family requires: "building families where needs are met, differences are accepted, rights are respected, and all individuals with- out exception are offered a platform from which to make a meaningful contribution to a better life in their home, their future, their community and the greater society" (UN 1994). The family as a social institution has an important significance. It plays a mediating role between individuals and society. It shelters, educates, nurtures and sustains its members, and more or less influences choices that they make in terms of improving their conditions of life. The family is also responsible for transmitting social and cultural values which are very much part of the inheritance passed on between generations. It is recognized that if social policies and services are to benefit individuals, especially women and children, they need to be sensi- tive to family dynamics and resource management (UN 1994; Cohen 1993). The family, as the world's oldest form of expressing human relations, is constantly adapting itself to changing socio-economic conditions and human progress. Hence, its strengths and weaknesses reflect the social fabric and character of every country or society. Families are universal phenomena and all individuals belong to one. Significant portions of people's life take place in the context of families, and hence their entire lives are affected by the nature of the family and its resources which also provide the environment for their growth and well being. Despite the changes in its nature and functions over the years, it continues to provide the context for emotional, financial and social support essential for growth and development of members, especially infants and children as well as the elderly, disabled and infirm (Sokalski 1993). DEFINITIONAL ISSUES The Family The family is dynamic and diverse. There is no simple view of the family, and neither should there be one. Thus, there is also no universally applicable definition. Perception of functions of the family, as well as notions of ideal relations within the family also differ among cultures, religions and nations. Families undergo constant changes and so do their forms, structures and functions. It is therefore difficult to identify a "generic" family. Major structural changes in the family are towards smaller units i.e. from extended to nuclear ones, and increase in single parent, female headed families and other non-traditional forms such as same sex and cohabita- tion, and performing, for example, socially assigned roles of husband and wife. Mental Health The idea of mental health concerns ensuring minimum conditions to make life more pleasant, meaningful, happier and worth while for individuals, families and communities in terms of their range of choices, opportunities and access to improved life situations. This is tied to the idea of welfare which relates to ensuring a certain minimum quality of life. It also strengthens the concern and justification for provisions to deal with conditions that are defined as stressful, or stress creating in the life of individuals and families (Kumekpor 1975). In defining mental health, the importance of psycho-social issues and conditions in an indi- viduals life must be recognised. The psycho-social model of mental healuV'focuses on emo- tions, conflicts, significant people, and problems of living as the group of irritants that are key factors in producing heabh or disorder. This model points to the person, his environment, and his associates" (Finkel, ti>76:9). Through this model a person is viewed as being capable of improving his/her mental health. Thus, defining mental illness (abnormality) goes beyond looking at mere behaviour. It is rather complex and must incorporate behaviour, context, place and time, and the socio-economic as well as political climates. Moreover, "it involves evaluation judgments in the form of norms plus values" (Finkel 1976:22). According to Robbins (In Herman and Freeman 1974), the best way to define mental health is to: — look at the various ways in which people live. First, consider whether they feel comfortable about themselves. Do they think of themselves as decent human beings? Are they able to form satisfactory personal relationships, get along with people socially? How do they look upon certain life experiences as unfair or unreasonable? Do the same demands that other people take in their stride upset them? Some of these demands are ordinary ones, just the simple ones. The mentally healthy person looks forward to and accepts new responsibilities gracefully and joyfully, (p.20) In the same sense, included in the requirements of mental health are self-esteem, a feeling of stimulation, a sense of community life, and environmental mastery. Other aspects of mental health mat have been emphasised include getting along with other people, progressive and dynamic adaptation to life in all its various situations, and the continued resolution of total situations so that personality growth is not arrested nor materially deviated. Thus, mental health is defined as an adjustment to the world and to other human beings with a maximiim of effectiveness and happiness. Based on this, it is emphasised that mental health covers all de- grees of the ability to adjust to the world and to other people (Herman and Freeman 1974). Changing Nature of Families The structure of Hie family is undergoing a transformation all over the world. A phenomenon which Africa has not escaped. Formalized marriage is losing its status, and divorce has in- creased in almost all countries. Traditional definitions of the structure of the family-nuclear and extended family - are changing too. The extended family (including polygamous ones) is being replaced by the nuclear family in urbanizing areas. However, the nuclear family too is under pressure from equality of sexes, technologies and economic status change of women. Non-traditional families such as cohabitation are becoming more and more common (UN 1994). In this range, one can also add single parent families and single sex alliances (families of choice). The institution of the family has been under great stress hi Africa over the past years due to war and violence, hyperinflation, urbanisation and commercialization, and education. Traditional practices and values are being abandoned - clan lineages are no longer that important. Even marriage has become more informal and fluid. However, kinship is still fee most determinant of identity within the society as this continues to provide support networks. The profound changes in family structure may be seen as a sign of decline; but despite the many pressures and challenges it has faced, the institution of die family has shown remarkable vitality and resilience. New forms of family life are emerging to meet the challenges of the modern world and are straggling to find more effective ways of balancing individual rights and social responsibilities (UN 1994). Socio-political transformations and upheavals in many societies have left many families in unusually difficult and alien conditions. Many wars or ethnic conflicts have forced millions of families out of their homes and countries, making the refugee situation in Africa unprec- edented in history. Recurrent and prolonged environmental deterioration, exacerbated by armed conflicts, and economic decline have all contributed to the disintegration of the traditional family and the vicious cycle of neglect, starvation and disease, all leading to helplessness or powerlessness. All these put immense pressures on families to adjust and adapt to the new conditions. These have led to adverse effects such as increase in emotional and physical strain in couples which also contribute to the rise in domestic violence and marital problems and disruptions. Eco- nomic hardship and demands have led to increase in child labour, and other forms of abuse in many instances. Because of the rapid socio-economic changes affecting both the roles and structure of the family, many families are at risk. According to the UN (1994), the concept of families at risk arises when families can not cope with problems in one area, and the effects are seen in other areas. This puts the family at risk of breakdown. Some risks that the family face are as follows: Those families in which individuals lose the sense of personal and group security, or in which individuals are exploited either physically, psychologically, or families at risk of breakdown due to social and economic factors; families facing risk factors such as domestic violence, drug and alcohol abuse and child and sexual abuse; refugee families who are at risk of being misplaced and face problems of being separated from each other, and are constantly threatened by insecurity, sickness and malnutrition; and single parenthood families which present problems, especially if the parent is a teenager due to lack of financial resources and lack of parental experience (UN 1994). Some of these risks can be predicted and prevented through long term measures such as educa- tion and public information campaigns, as well as improvement of the status of women. Despite these risks and the fact that many families are under-stress, we may be witnessing and participating in an overdue revolution in the family in which basic questions about the way we live our lives, with whom and how, are being questioned and debated. Nowadays, we constantly hear that "the family" is in trouble, that we must find ways to strengthen it We see headlines such as "Divorce on me rise", or "Alanning new figures on child abuse", and we conclude mat we must do something about "the breakdown of the family (Hite 1994). The unspoken premise according Hite (1994) is that the ideal of the family, as traditionally defined, is a wormy goal that immoral or selfish people have failed to achieve. Hite (1994) argues mat before accepting mis orthodox, we need to look at the alternative view that the traditional family system has failed and that women are taking up more democratic fulfilling and practical way of life. This may be one of the most important changes leading to the creation of a new social base to enhance, advance and improve democratic structures. Now that families are becoming different, we are seeing people question things in their upbringing that for centuries have not been questioned. The family, that is, human love and support systems, is not in danger of collapsing. What is happening is that finally, democracy is catching up with the old hierarchical father dominated family. The family is being democratised. Many men, like many women, have discovered that trying to copy one original personal life style does not allow them to relate honestly to those around them. So they are seeking to find out what works in their own lives incorporating democracy which is so much praised. This has led to the new changes in lifestyle, at least in the western world, which is slowly catching up in Africa. The alarming increase in single-parent families is in fact a clear indication that women are-no longer playing the traditional roles which make them subservient. This should be respected because most of these women who have found themselves as single-parents are divorced and believe that giving love and warmth to children is better than preserving the outward appear- ance of normality. Similarly, cliches about "nagging wives and husbands" and "needing to be free" and not "being tied down" show the desire of both men and women to be free of tradi- tional roles (Hite, 1994). It must be accepted that there is now a wide choice for individuals as to the type of family they want. The emphasis is shifting gradually towards fulfilment of individual needs on a non- sexist basis, and perhaps away from unconditional family unity, tolerance and acceptance. Most African families are also adopting trends away from traditional patterns which include high fertility, life-time marriage and full-time housewives towards a more modem type char- acterized by low fertility, one or more divorces, and most wives employed away from home (Krausz 1994). Given this family dynamics and the conceptualization of mental health discussed above, the question can now be put thus: What are the requirements of a holistic approach to family mental health? A Holistic Approach to Family Mental Health A holistic approach to family mental health requires a process that starts with the mobilization and empowerment of families, and especially women as individual family members. The aim should be to provide continuity, security and dignity to the family members in their relation- ship with their environment. A family focused framework, therefore, must identify what makes sense for households and individuals while recognizing that the family is the bam: unit of society; how the family can be a partner in resource acquisition, distribution and utilization; and how it can be used as a unit of analysis to examine how social and economic relationships (within families) constrain and support access to the control over resources, and responses to policies and programmes. Effective development at the grassroots, requires empowering family members to take charge of their own development and to successfully negotiate for access to both internal and external resources which they can relate to, and control. For effective and sustainable development, therefore, as a prelude to mental well-being, a holistic approach must be in the context of bringing all family members to the equation as active participants even when the target is an individual. This means paying attention to intra- and inter-family dynamics while keeping focus on the need to empower women, men and children economically and politically (Cohen 1993). This strategy means understanding families and how they control, manage and access resources; and recognizing that families are experts in the choices they make based on affordability and individual and group development strategies. We need to understand not only the "what" of family decision making but also the "why" of intra family resource management. This will enable cooperation with households at the grass root level, because of the understanding of factors which drive family activities. A holistic approach to mental health of the family must be based on the recognition of the fact that mental health and social service delivery in general, have medical, social, industrial, economic, political, and other aspects. Thus, it is important that these are considered as inter- related parts of a single, unitary process rather than as separate; and that specialists concerned with the various aspects should work as a team. Above all, there must be a closer relationship between the medical and social aspects of service provision (British Information Service 1962). The essence of service provision in this case, is to make a person, within a family context, as independent as possible in everyday life. This is based on the notion and the belief that health by the people is possible and most desirable, and must form the basis of a family health care system. Tn operationalizing this concept of holistic care, there are two kinds of goals that must be pursued simultaneously: a) b) Technical goals: These are concerned with scientific and related developments focusing on such areas as, education, agriculture, health, sanitation and housing. The attainment of these goals requires the assistance of technical experts to help plan, advise, teach or perform the necessary tasks in which they have the training and the skills. Social goals: These are concerned with human relationships, and with the develop ment of participatory processes managed and controlled by families at the grassroots (Midgley 1986). Issues of participation are built on the idea of voluntary and democratic involvement of fami- lies in: a) b) c) Contributing to the development effort; sharing equitably in the benefits; and decision making in respect of setting goals, formulating policies and planning implementation (Midgley, et al 1986). Other elements in the concept of participation are autonomy and self reliance. However, de- prived, poor or disadvantaged families cannot function autonomously without having first been made aware of then: capacity for independent collective action and taught the techniques of interacting with external bodies. The process requires the inculcating of attitudes of confi- dence and cooperation, and the ability to organize. It is argued that participation cannot be improved without a few structural and role changes in the family. For effective and meaningful participation, there must be free flow of relevant information and knowledge. In addition, all family members must have unhindered access to this information and other relevant external resources. Thus those who have been traditionally dependent on and controlled by others with the family contexts must be free to perform or function under democratic principles and ideals. The discussion on models of mental health service is not a new one. The discussions and debates which were intensified in the 60s, have not abated in the 90s. For those of us in Africa, the search for a model of mental health service which is appropriate for our environmental conditions - available human and material resources, values and system of beliefs is an urgent one, if we are to achieve any remarkable results in the field. For the purposes of this discus- sion, I wish to emphasize Die family based approach, which is the basis of the "Social Strat- egy" approach. This approach is borrowed from the field of social and community develop- ment and focuses on the family as the basis of all forms of development. Family involvement helps in the mobilization of grassroots resources, collection of information needed to initiate and adapt a service to local conditions, transformation of conditions in order to bring about social change, and enhancing of a family's ability not only to build structures but also to create a basis of continuity and maintenance. The strategy calls for institutional reforms which allow the involvement of all members of the family in the provisions, delivery, and maintenance of services (Osei-Hwedie, 1989). Planning and policy in the area of mental health, therefore, as a necessity, must focus on total individual and family development, including health, productive and participatory abilities and skills, maturity hi socio-political decision making, and cultural experiences. On the whole, among the major strengths of this approach is that it focuses on integration too. This aims at bringing disadvantaged or isolated and peripheral families and individuals into the mam stream of development (Osei-Hwedie, 1985). On the whole, we need a new socially relevant health system. It is emphasized that efficient and effective delivery of mental health services depends largely on how well mental health care can be integrated into a family's social system. This family social health care system depends, by and large, on socio-economic factors. The system, on the whole, requires and insists on the involvement of non-psychiatric or non-medical health personnel in the care for the mentally ill; maximum and efficient utilization of family resources-including values, and beliefs; and most importantly, the maximum participation of patients and their social net works (Lin, 1984). Impact on mental disorders may come from concerted, coordinated, and sustained efforts to attack all forms of deprivation. These efforts include those aimed at mobilizing the family and its resources to improve nutrition, promote immunization and community hygiene, expand maternal and child services, and improve the general circumstances of living of the family. These are necessary because mental health conditions relate to abject poverty, hunger, and disease. Thus, with adequate nutrition, clean water and general environment sanitation, regu- lar health examination and quick treatment, a lot could be achieved hi the area of mental health (Stem, 1984). It must be emphasized that mental health involves more than the absence of sickness or dis- ease. It is not only a private affair but also it is a public issue which involves people and their ing "social networking system" in order to establish and sustain a socially supportive environ- ment The emphasis, therefore, can and must be placed on developing the family's social potentials and better ways of coping (Binhe, 1984). In short, the focus of any mental health service should be the incorporation of socially defined, family-based, essential elements of. prevention, diagnosis, care and rehabilitation as part of the overall essential services. This allows for the incorporation of indigenous and other types of service-delivery systems (Stein, 1984). Throughout history, attitudes towards the mentally sick have been unfavourable and those labelled as mentally sick or ex-mental patients might have been unfairly treated because' of this. One major obstacle in trying to help the mentally ill and ex-patients lies in family's (as part of community) negative attitude towards them. Studies have shown that most people, whether young or old, highly educated or with little schooling, feel that the mentally sick are "dangerous, dirty, unpredictable, and worthless" (Thio, 1983: 294). It is based on such atti- tudes that, for example, ex-patients are denied access to family resources and meaningful interaction with other family members. These views of the concept of family mental health expressed here assume that, to promote mental health, destructive social forces that contribute to mental illness (such as poor housing, unemployment, disillusionment, negative social relationships, lack of social supports, socio- economic and political alienation, and problems of social adjustment) must be contained. The promotion of mental health, therefore, becomes a major component of the issues that have been the traditional domain of politicians, community groups, planners, social scientists, edu- cators, social workers, lawyers and medical practitioners, among others. The day to day reali- ties of poverty, unemployment, social maladjustment, and stressful relationships that impact upon families and need to be solved, are relevant to our present and future mental health as family members. Conclusion On the whole, we need innovative, flexible and culturally relevant processes of social services provision, services that minimize isolation and loneliness and promote family and communal spirit, hi addition there must be a healthy and habitable family environment as well as avail- ability of relevant goods and services. Mental illness cannot be tackled by half-way measures and half-hearted, static efforts, part time interests and investments. It is a massive problem mat demands full and dedicated support from all members of the family. The family, in this regard, is the core of the solution and that is where we must begin our search for answers, resources, skills and procedures that are manageable and sustainable. Bibliography Binite.A 1984 "Mental Health and me Third World " In Nann, R.C. (ed.) Mental Health; Cultural Values and Social Development: A Look into the 80s, Dordrecht, Dr. Reidel Publishing Company. British Inf. 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