Making a difference in resource-limited settings

There is something about the connections between interventions, contexts, systems, and people that are very important in determining if a difference is going to be made. Trying to understand these connections and systems has been a major part of my career.

When I was an undergraduate student of psychology in Ottawa in the mid 1990s I volunteered at a drop in for homeless people. I had no real idea about what I was supposed to be doing there aside from keeping the tray of stale pastries stocked. One of the first clear directions that I received there was from a man with a long grey beard and severe tardive dyskensia – tremors brought on as a side effect of anti-psychotic medications. Seeing me standing around he invited me to be a fourth in a card game. From then on, playing cards was one of the things that I did there – hanging out, chatting, and joking with a small group of regular card players.

This kicked my thinking about the problem of how interventions work – in this case it was the juxtaposition between people who were very badly failed by existing systems, services, and treatments and something that was happening in those card games… a sense of community, a brief respite from some terrible realities, and mutual support.

This kind of a question has come up time and again – co-leading an informal arts-based group for sex trade-involved homeless youth that saw better engagement than more structured approaches…entering the margins of burnout in a Detroit crime victim service where I tried to make sense out of the brief interventions that we offered to brutalized young people who were promptly sent back to the same violent, impoverished environments that put them in hospital.

In each instance many questions came up about how interventions work for marginalized people in adversarial, low resource contexts.

One way of tackling these types of questions that myself and some colleagues have taken in recent years is the approach of trying to learn from those who have had the greatest success in generating interventions that make a major difference for marginalized people – interventions that last and grow. We developed a partnership with Ashoka – global experts in finding the exceptional types of people that we sought. Our first effort focussed on Toronto, where we identified a model for service development relevant to high income contexts. Most recently, with the support of Grand Challenges Canada, we have taken this search to a global level – again partnering with Ashoka to intensively study what has been instrumental to the success of mental health sector leaders in a range of low-middle income countries.

The Grand Challenges Canada work has been a remarkable experience. We did intensive case studies with 5 organizations addressing a range of issues: addictions in Colombia; developmental disability in Egypt; acid violence in Bangladesh; severe mental illness and poverty in an array of countries. Despite the many differences between these organizations and their contexts, a common model of development emerged. We saw leaders deeply embedded in the challenges that they were addressing – applying a systems understanding and finding points of leverage in addressing problems where every investment of resource generated the greatest possible amount of impact. From client and community, through to volunteers, staff, leaders and partners, we saw cultures of empowerment and alignment to values and mission. The livelihood of clients was a major focus.

Furthermore, these organizations intensively worked to generate social capital around their work,  employing an array of common strategies to encourage community, public, and policy support.

Overall, this has been an exciting step in this line of research which is a part of a larger effort to understand how to build interventions up to the task of tackling complex mental health challenges in very challenging settings. It has pulled together the concepts of social entrepreneurship, science of delivery, and system dynamics theory. Along with academic publications (PLOS and Springer), we have generated a guide based on our time with some of the most successful mental health interventionists in the world, capturing ideas and strategies that we hope could enhance the success of others.

If one fundamental point has been made clear, it is that in a global context where the stigma of mental illness is rampant and where there is a sharp misalignment between the burden of mental illness and the resources applied to it, it is imperative that we attempt to learn from successes.

These successful interventions help highlight gaps in current research and practice, provide examples of paths forward in a field characterized by many frustrated efforts, and bring a focus on how investments can make a major difference.


Partners and collaborators on our Grand Challenges Canada study include Ashoka and Ashoka Canada, BasicNeeds, Kwame McKenzie, David Wiljer, Athena Madan and Susmitha Rallabandi (CAMH), Donald Cole (Dalla Lana School of Public Health), Elisha Muskat, Susan Pigott, and David Aylward (Ashoka), Shoba Raja (BasicNeeds).

This post was originally published on the CAMH Blog.

Empowerment and service user involvement
Task sharing
Treatment, care and rehabilitation
Training, education and capacity building
All disorders
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Thank you for creating the guidance this blog refers to. I found it very useful. It helped me realise that I have been a social innovator in Mental Health for 17 years but had not fully realised that was what I have been working at motivated by personal experience of receiving very poor mental health treatment following complex trauma and having multiple needs. I felt very encouraged by the examples given by the perseverance of the leadership in each organisation and their ability to adapt to the local context in order to meet the needs of their tiger beneficiaries. This has encouraged me to persevere and the questions asked helped me reflect on the next stage on developing my Ladder4Life approach for creating Reflective Learning Communities for people with complex needs which can be integrated into existing service provision such as homeless services. I'm also looking forward to connecting with other social entrepreneurs in Mental Health through this network as the traditional status quo is extremely poor and in need of innovation. Thanks again. Ray

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