Stephanie Hepburn is a writer in New Orleans. She is the editor in chief of #CrisisTalk. You can reach her at .
Community-based health care is often woven into the policies of Western nations, based on the idea that people should have access to and receive help within the communities they live, says Steve Appleton, CEO and president of Global Leadership Exchange, formerly the International Initiative for Mental Health Leadership.
In some populations, the concept of community goes further. It’s less about the buildings and services within an area but instead focused on people, non-professional members of the community, supporting one another.
Those helping someone navigate a crisis might be the person bagging their groceries, filling up their car at the garage, says Appleton. “On the Pacific Islands…it’s not the buildings or the professionals, it’s the people,” he said, adding the approach creates a community “where it’s OK to talk about when things are tough.”
Like elsewhere, there’s clinical support, but geographical spread means people face challenges getting to those services and the community becomes the first line of intervention.
On the Pacific Islands, people, together, are a safety net.
Discussions on differing views of community-based health care is one of many dialogues that have come out of biannual thought exchanges. Mental health leaders from nations around the world network and attend matches, where they’re matched to specific themes in mental health, substance use and disability.
Last year, thought leaders met in Utrecht, Netherlands, to discuss, among other topics, building community in polarized societies and mental health and disability in conflict zones, where experts from Ukraine spoke.
These discussions provide vital information for other nations experiencing similar struggles, whether wartime, civil unrest or even natural disasters. Similarly, nations with large rural swaths can learn from those who’ve built a different kind of community support.
Global Leadership Exchange (formerly IIMHL) regional hub network convening in Washington, D.C., in 2022.
The objective, says Appleton, is not only the dissemination of knowledge that takes place during the biannual leadership exchange convening, and collaborative groups and networks the international nonprofit runs, but also ensuring people of differing types of leadership and responsibility have the opportunity to share their knowledge.
“Expertise shared on an equal basis creates parity of esteem,” he said. He believes an environment where all leaders have a voice makes dialogue on innovations, challenges and solutions between nations all the more fruitful.
That the exchanges are in person matters, says Appleton. While he’s no Luddite when it comes to technology, he does believe people gain more from in-person dialogue than from virtual. “We place a lot of value on the relational element of knowledge exchange…being able to sit down in a room with a group of other people,” he said.
“It’s also about building relationships that become more personal, that create a friendship and enable you to connect and support one another.”
As nations increasingly focus on their mental health emergency and crisis systems, and law enforcement diversion, exchanges are all the more dire. How that looks in the U.S., highlights Appleton, may differ from the U.K.
In the U.K., health care is universal. “No one in England is going to be asked to produce their credit card before they get treatment,” said Appleton, noting that though the U.S. doesn’t have universal health care, it spends more per person for those insured by Medicaid or Medicare, “yet has worse health outcomes.”
“People in the U.K. are just going to receive treatment and not get sent a bill at the end of it. That doesn’t mean they’re not paying for it because they are paying it through a taxation model.”
The National Health Service isn’t perfect, Appleton says, and can result in “quite long wait times for services.” “Sometimes, there are underdeveloped parts of service, not just in mental health but also physical health care.”
Differences between nations don’t preclude learning from one another but it does mean there’s a careful balance between standardizing crisis responses across nations versus tailoring them to be population-specific.
In most nations, including the U.S. and U.K., there are challenges around demand and access, with demand for mental health services rising amidst a global health care workforce shortage. The chasm means people are more likely to receive a law enforcement response or be caught in the criminal legal system.
Some nations are moving away from law enforcement as the first responder to a mental health crisis, a movement often led by police. “They’re saying, ‘Look, we aren’t care providers, we are here for public protection,’” said Appleton.
He says the debate is nuanced because a person in crisis is also a member of the public and needs to be protected. “You can’t abdicate your responsibility to the individual on the basis that it’s only the rest, or everybody else, who you’re trying to protect.”
In the U.S., improved interoperability and partnership between 911 call centers and the 988 Suicide and Crisis Lifeline contact centers — and mental health crisis call diversion programs on the 911 call center floor — have been instrumental in diverting suicide, mental health and substance use crises from a law enforcement response when possible. However, the nation is simultaneously facing behavioral health workforce shortages, particularly in crisis services.
Appleton highlights that in the U.K., police have felt they’re not there to “plug the gap of health care professionals” and they’ve been responding when it should be mental health professionals doing so.
“What countries should be looking for is a multidisciplinary, multi-sectoral response — a shared responsibility of public servants more broadly, whether law enforcement, ambulance services or social workers, to work together and think about the needs of the individual.
“What are their needs, not just the crisis they’re presenting in, and how do we respond to the immediate crisis and follow up?” He says not having follow-up perpetuates the situation where another crisis is likely to occur.
Appleton believes there’s an opportunity to standardize language around mental health and what represents an appropriate response, especially regarding timeliness. What defines a mental health emergency versus a crisis? What defines acuteness? “Somebody could be having a crisis but may not be in acute danger or at acute risk either to themselves or other people. Or they could be in an emergency and at risk.”
However, he says standardization in how responses are delivered would be difficult because that is often specific to people’s locations and circumstances. “What works well in Nebraska may not work well in New York City or London,” he said.
Also, responses must be tailored to the community and population needs. For instance, in Zambia, where mental health stigma remains high and people are hesitant to admit they’re struggling, talking about mental health may look different than in other places or communities. In the U.S., in high-stigma communities, language is often centered on wellness, stress and stress management.
“There’s cultural and geographic relevance you probably can’t standardize out but you could have principles about responsiveness.”
The exchanges, says Appleton, are about sharing models colleagues of different backgrounds and viewpoints can build on or subtract from to ensure relevance to their nation and populations. “We want to help build interpersonal relationships and an international community of practice and learning to help people understand one another, to be alongside one another, and shape new ways of working, new ways of delivering care, informed by best practice, wherever it might be…whether it’s your neighboring country or remote Australia, Fiji or Zambia.”
