From prevention to promotion

While co-assessment has made it possible to construct a cross-border alliance, it has also, more importantly, facilitated the emergence of a common culture where prevention in matters of health is directly linked to promoting health which, though it may be more difficult to establish, is also more ambitious. “In order to understand the notion of health promotion, you have to go back as far as the Ottawa Charter of 1986 , explains Gaëtan Absil. The idea is to regard health not as something that is constantly threatened by illness, but rather as a positive resource which serves to help the individual to contribute to the development of a community. It allows individuals and communities to become involved in social issues relating to health. In this way, health constitutes an important political issue. Health promotion participates in the struggle against stigmatization and the aids in the reduction of social inequality”. At the end of the day, it is a more “social” vision of health which is put forward in a so-called socio-ecological context. This movement acts as a counterbalance to the tendency to see social problems in psychiatric terms, something which has been pointed out by the participants in the project who often refer to the often abusive use of the DSM (Diagnostic and Statistical Manual of Mental Disorders) as a “model for reading about social issues”.

Promotion implies the idea of “empowerment” which would serve to reestablish the sense of initiative of the community - identifying whether I or one of my nearest and dearest needs help - but also the critical conscience of the community with regard to mental health problems. “For example, the promotion of mental health could help parents to resist improper diagnoses of hyperactivity”, comments Pascale Esch, development psychologist and author of a thesis (under the supervision of Prof. Marc Ansseau) on the early detection of mental disorders linked to school failure. What this collective project underlines, is the ambiguous nature of the concept of prevention which, not being based on the idea of promotion, encourages the pathological approach to mental health or social problems. Prevention is, in fact, never far from being a “zero-risk” fantasy which reinforces the dividing line between normal and pathological and drives a deterministic idea that has an excluding and paralyzing effect. “This holistic vision attached to health promotion is necessary so that prevention actions can succeed”, insists Pascale Esch. From a political point of view, promotion remains difficult to defend: long-term vision, effects that cannot easily be measured, more collective than individual ambitions are added to the fact that it presupposes, in conformity with its global approach, the collaboration between different professional spheres. While prevention is seen in a good light due to its pragmatic nature, health promotion is quite the opposite by virtue of its unlimited potential with regard to forcing change.

The user as a driver of destigmatization

The promotion of mental health is the only thing capable of permanently erasing stigmatization, which itself has been seen to be an essential cause of discrimination, loss of self-esteem and suffering… much in the same way as or more than illness itself. This struggle today requires the involvement of users who are not part of the public debate. The current status of Belgian reform of psychiatry "psy 107” is a good example because, in spite of the hospital-centred criticisms that have been levelled against it, it has, from the outset, invited the user associations around the same table. In the same context, the work directed by Laurence Fond-Harmant is accompanied by a DVD which gives a voice to these users, not simply by making them “witnesses” but by recording their opinions on the issues of promotion and prevention. “Destigmatization is directly linked to the ability of these persons to be participants and citizens: whenever they are considered to be “sick individuals”, their opinions are systematically reduced to being merely those of patients. In this context, what is the value of their words? Gaëtan Absil asks. And Laurence Fond-Harmant adds: “Whenever an opinion raises inconvenient questions, there is a tendency to associate it with somebody who does not have the ability to express an opinion with clarity”.  

It is true that the involvement of users constitutes a veritable shake-up of the medical establishment: it topples hierarchical relationships, opens a breach in established protocols and poses the question of legitimacy of experience against that of transferred knowledge. A certain section of doctors continue to reject this expression of opinions by patients. “The users are therefore regarded as a militant who simply transfer them from one type of stigmatization to another, considers Gaëtan Absil. These tensions lead to the belief that mental health should not only be promoted in relation to what is considered “wider public”, but also actors in the medical field themselves. “Health professionals have been trained all their lives in the bio-medical aspects of illness. Returning to a more collective than individual approach to health is almost a process of unlearning which requires them to embrace another approach to work”. In conclusion, this empowerment of professionals could replace the issue of loss of power with a more across the board approach whose efficiency in terms of “good living” is much to be desired.

 World Health Organisation, Ottowa Charter for health promotion, 1986.