By helping community health workers learn how to recognize and deal with the most widespread forms of mental health problems, Benno de Keijzer is bringing urgently needed help to millions of seriously ill Mexicans and their families in areas or at income levels where psychiatrists are exceedingly rare. In the process, he is stimulating the development of a new field of popular psychological care that listens to and incorporates local and historical cultures and their ways of thinking about and dealing with mental health.
The New Idea
Benno is working to fill an urgent theoretical--and very practical--gap in community medicine, both in Mexico and throughout Latin America, namely, the lack of an appropriate model for dealing adequately with mental sickness.While communities and their neighborhood health para-professionals have learned that medical knowledge is not the exclusive domain of university trained doctors, and have started to deal with a great number of health problems themselves, the same situation has not developed in the field of mental illness.Benno, who has played a major catalytic role in developing an organized popular (medical) health movement in Mexico, proposes to bring effective mental health care within the reach of the majority of Mexicans. While recognizing that many specifics are different, he believes that many of the basic principles at work in the popular health movement will apply to the mental health field. For example, he believes that it is essential that local communities themselves learn how to deal with mental illness. Benno's beginning point, therefore, is training local general health promoters how to recognize and deal with mental disorders. For Benno, this is a process of listening at least as much as training. Probably in the long-term, the most innovative aspect of his work resides in his openness to incorporating traditional language, categories, and curing techniques for mental illness into a wider theoretical framework. Too often "modern" medicine dismisses as illogic or witchcraft approaches that have been effective but that come from non-Aristotelian ways of thinking. Especially in the area of psychology, the healers must connect with the minds of their patients on the patient's terms in order to succeed.
Although there are few reliable statistics, mental ill health is a major burden for much of the population, either as a direct affliction or indirectly as one person's illness affects their family, workplace, and community. Since Mexico is now in the middle of rapid urbanization and structural economic change (and dislocation), Mexicans are experiencing higher than average levels of stress and disruption of key support structures, such as the family. As a result, the incidence of mental ill health is probably above the global average and rising. (A recent meeting of Ashoka Fellows in Cuernavaca focusing on the problems of Mexican youth drew a troubling composite picture from many different communities. It began by summarizing many of the breakdowns and sources of disillusion facing young people, ranging from missing migrant laborer fathers to dismal job prospects. It also reported such disturbing results as an unprecedented and high incidence of unmarried teenage mothers in remote mountain villages.)
One of the reasons the statistics are so alarming is that the problem of mental ill health is difficult to measure. It's not like other more easily identifiable illnesses since it can take a variety of forms: insomnia, anxiety, depression, addiction, obsessive behavior or hysteria, to name but a few. Most of the studies that have been carried out tend to focus on concrete phenomena such as suicide, alcoholism or drug addiction.
Benno's initial studies, done in coordination with other health PVOs, point to four major areas of mental ill health that are well-suited to community level care:
1) Physical sickness with a strong psychosomatic basis such as gastritis, colitis, insomnia, skin diseases, backache, headache.
2) Family problems related to emotional conflicts between couples and their children.
3) Addictions, in particular to alcohol.
4) Anxiety and depression produced by social and economic problems.
Despite the scope and importance of the problem, trying to bring mental health care to the majority of Mexicans is largely uncharted terrain. Even though Mexico has an active popular health movement and there are a wide variety of PVOs dealing with diverse aspects of community health, the issue of mental health has been largely ignored with the limited exception of the substitution of some herbal remedies for anti-depressants and tranquilizers. Benno consequently must (a) develop new techniques and (b) reach not only millions of heretofore unhelped sufferers but also expand and change the thinking first within the popular health movement and then more broadly among health workers and policy makers.
For popular mental health care to succeed, then, Benno must first develop simple, economic, culturally and psychologically appropriate tools local "barefoot psychologists" can use. He then must persuade both clients and practitioners to accept this new/old combination. Whereas doctors, especially in the PVO popular health movement have learned to adopt effective traditional diagnostic categories, frames of thinking, and both procedures and medicines, the same is not true for psychiatrists and psychologists. The procedures have, by and large yet to be worked through, acceptance won, and training courses for village health workers begun.
Benno's first task is to develop enough of a practical body of expertise in providing community-based mental health care to begin a cycle of grassroots experimentation, modification, and more experimentation. Once this process takes hold, it will produce more and more results, adherents-cum-experimenters, and then again more results. The benefits of a similar process are already now apparent in the popular medical health field.
Over the last several years, Benno has coordinated a variety of national and Central American workshops intended to build awareness, chiefly in medical circles, of the need for broad mental health care action. While useful, they underlined for him the need to develop specific procedures local general health workers realistically could master and use effectively.
Consequently, over the next several years, he will devote a major part of his time to establishing both an array of such practical means and an overall theoretical framework for dealing with psychological disorders at the community level. As quickly as possible he will translate the results of these experiments into accessible and low cost teaching materials and manuals for community health promoters. In the interim, these draft materials will help focus local experiments. After testing, discussion, and revision they will carry these reforms far and wide.
Developing these tools and an overall framework will involve not only researching the different perspectives offered by psychology, anthropology, and cultural sociology but also, and probably more important and congenial, working together closely in action research with the promoters. Only this way, Benno feels, can a methodological proposal for training mental health promoters be worked out which will in turn have a broad application. His initial focus is on the following topics: identifying common patterns of poor mental health, the role of the health para-professional in dealing with mental illness, a guide for counseling, techniques for helping the family, and alcoholism.
Benno was born in Mexico of Dutch immigrant parents. He initially trained as a doctor at the national university. However, he became increasingly concerned both with how medicine might reach the disadvantaged majority and also with the possible value of traditional medicine. These interests led him to undertake studies in social anthropology.
After completing his studies, Benno worked for several formative years in health education in Central America, principally Costa Rica and Nicaragua. He returned to Mexico permanently in 1982 and became involved with a group serving popular communities in Mexico City and helped it introduce many of the lessons he had learned previously while serving some of the region's most disadvantaged communities.
From this base, he was instrumental in setting up Mexico's major network of popular health PVOs, PRODUSSEP, where he served as Executive Director. Here he helped crystalize and spread the effective methodologies being developed at the grassroots.
Benno's vision and commitment to bringing effective mental health care to most Mexicans grows out of the several major strands of his life experience so far -- seeing the urgency of the need at both the rural and urban grassroots and having played a central role in helping medical workers learn how to provide appropriate physical health care to the majority through community self-help and the good sense to listen carefully to his clients.