#EMentalHealth: Digital interventions blended with traditional care.
…what is E Mental Health?
E Mental Health has been around for the last 50 years, perhaps more, in a rudimentary fashion using two-way radio and landline telephones. The idea of consulting with, and supporting, patients (and their families) using communication technology is well established. We have been using telephone services in mental health for many years, but in recent times, E Mental Health has snowballed to include a wide range of electronic and digital technologies enabling mental health promotion, early intervention and longer-term treatments in both stand-alone and blended care formats.
Increasingly, it is seen as a viable and cost effective strategy to integrate or blend care within a comprehensive suite of mental health service delivery options, making it possible to help more people at a time and place of convenience to them (Wilson R. L. & Usher, 2015). A wide range of digital interventions are emerging, however not all of them has been validated for safety and efficacy in clinical trials. Never-the-less, it is known that positive engagement in mental health interventions (especially where behaviour change is required) is improved where technology-based strategies are included in either standalone or blended therapies (Alkhaldi et al., 2016). Digital interventions can be described as “programs that provide information and support – emotional, decisional and/or behavioural – for physical and/or mental health problems via a digital platform” (Alkhaldi et al., 2016; Bailey et al., 2010).
E Mental Health is expanding into new and exciting areas of practice, and for clinicians and health researchers, this is a particularly dynamic time. The general community are engaged and ready to use E Mental Health innovation (Fox & Duggan, 2012). More than that… people now expect to find useful mental health information, support and even treatment in digital formats (Fraser, Randell, DeSilva, & Parker, 2016). People expect to access E Mental Health in a range of forms as simply and quickly as pulling their smart phones out of their pockets. Increasingly, a ground swell exists for self-care E Mental Health and this is gaining widespread popularity (Alkhaldi et al., 2016). Many people prefer to receive, information, guidance and even treatment in the privacy, and comfort of their own homes where they remain connected to their place and daily practical life competencies that underpin their optimal wellbeing (Bissell, 2013).
The 21st Century E Mental Health reality is that health care professionals can deploy a virtual mental health clinic in the pocket, handbag, or backpack of the majority of people in the developed world, and for many people in developing countries also (Brusse, Gardner, McAullay, & Dowden, 2014; Wilson, Ranse, Cashin, & McNamara, 2013). The global opportunity that is available by using the personal Internet connected smart devices of individuals everywhere has enormous potential and capacity to promote mental health, and to reduce the burden of global mental illness (ICT Data and Statistics Division Telecommunication Development Bureau Geneva Switzerland International Telecommunications Union., 2012; Proudfoot, 2013). These are exciting times.
3 main categories for E Mental Health services:
- Web 1 & 2.
voice & text…
- Two-way radio UHF services where mobile or cell phone coverage is poor (for example, Royal Flying Doctors Service in remote regions of Australia).
- Call centre-based services to triage and arrange intake or referral to individuals seeking entry to mental health care services (for example NSW Health free call numbers in Australia) (Elsom, Sands, Roper, Hoppner, & Gerdtz, 2013).
- Call centre-based services to crisis mental health help lines (for example Australian services such as: Lifeline, Suicide Call Back Service, Kids Help Line). Similar services are available in most countries where free public mental health care services/insurance also exist.
- Most countries have an emergency service free call telephone number such as 000 in Australia, 911 in USA, 112 in Europe and 999 (or 112) in the UK.
- Mobile/cell phone SMS or text-based services (“Nancy Lublin: Texting that saves lives,” 2012).
- Telepsychiatry – frequently refered to as video links between health services where the consumer or patient and/or carer is in one location, while the specialist mental health clinician/s are in a separate location. A synchronised time is arranged to make a private video consultation link-up. This allows people to receive specialist care without the need to travel to a far away appointment in a distant location (for example Queensland Health (Queensland Health., 2013; Statewide telehealth services., 2013) and )
- More recently Skype has provided a platform that enables flexible video based consultation and added an element of convenience and simplified technology.
web 1 & web 2…
- Email usage and web browser literacy is now generally considered to be a basic life skill for adults, where an integration of web literacy develops as people are able to explore, build and connect relevant information that is useful to them and for solving a range of problems from a self help perspective. For example: Browser search engines such as Google and associated free email host services such as gmail have provided a virtual and digital context where people are more able to search for health information aligned with their health needs and specific health question.
- Web 1 has provided a platform for health care professionals to develop static information and education resources for the general public (for example: beyond blue, black dog), and also website based intervention tools. For example Cognitive Behavioural Therapy (“myCompass. Introductory video,” 2010) and Mindfulness Based Therapy.
- E Mental Health electronic patient records such as the European E health action plans and in Australia (Australian Commission on Safety and Quality in Healthcare., 2016).
- Call centre-based services have been able to add value to their telephone services, by providing extra general information on website connected to their services so that they can support callers further. (For example: Lifeline)
- Web 2 has expanded the options available even further by integrating all other options with a synchronous real time, and asynchronous convenient times, social media enhanced interactive experience that is particularly convenient to the general population, and it is this element of E Mental Health that offers particular promise as new service and interventions are developed.
- Smart devices, and especially smart phones, facilitate the opportunity to utilise apps to enhance the mental health service portfolio, with many apps currently available as information or treatment services.
- Personal electronic accessories such as fitness monitoring devices (eg fitbit or the apple watch) that sync activity levels, such as heart rate, calorie consumption, with smart device diary tools to monitor health characteristics and behavioural change. Fitbit has demonstrated effectiveness as a monitoring tool to enhance engagement in self-care and promoting health and wellbeing generally. The integration of these personal monitors into health care is gradually occurring.
- Gamification in E Mental Health, enhancing engagement in mental health self-care, and gaming-based interventions is an area of particular growth. Gamification introduces a fun and engaging way to interact with health promotion, digital intervention and to foster behavioural change with the added incentives and motivation of providing rewards for efforts. Some gamification is simple and brief such as gif files that prompt and guide breathing to assist in reducing the experience of panic or anxiety.
- More advanced gamification is used to connect with various populations, for example, young people. Integrating gamification software strategies into mental health promotion and strategies will target at risk populations.
- Social media is a useful platform for teaching the public, student health professionals and less engaged experienced clinicians about mental health information and clinical skill development. We know that many health professions students prefer to gain their discipline information for social media such as Facebook (Usher et al., 2014). We also know that a growing number of health professionals are using social media to create virtual communities for research, practice, knowledge exchange and mentoring purposes.
The common usage of personal smart phones and access to computers and other smart devices has driven a level of integration so that we are now in an era where voice, video and web-based resources are available, and often in a blended format so that all three can be use simultaneously and either in synchronous or asynchronous formats. This provides service users and service providers with a level of flexibility and convenience not seen previously.
commercial & social enterprise influence in the E Mental Health arena…
Plenty of innovation in the field of E Mental Health is occurring at a rapid pace, with commercial and social enterprises quick to respond to the global appetite to address mental health problems generally. There are many apps and websites to choose from – some with costs, others free to access. This dynamic has both risks and benefits associated with it.
- A general population wide awareness and expectation about accessing mental health information and support in an electronic environment.
- Populations skilled and literate in the use of electronic devices and digital technologies such as apps, web site navigation, email and social media.
risks and limitations…
- The trustworthiness, reliability, dependability and credibility of many E Mental Health activities in the commercial and social zones are not known because E Mental Health research and development occur at a slower pace than the commercial and social environment, and with a rigorous process to demonstrate efficacy and patient safety. Thus, health service providers and clinicians are reluctant to engage in E Mental Health initiatives with out best practice rigour to support their practice.
- Clinical trials take a significant amount of time, planning, design and testing to underpin evidence to support safe practice. In the context of the rapid pace of change in the E environment generally, this poses a challenge.
- Not all clinicians are keen adopters of social media generally. Thus a digital literacy and skills base has not dominated the health environment generally to date. The mental health workforce is aging in the international sphere, and as younger and digitally literate workforce enter the mental health professions they will bring with them the ease and comfort of existing and operating in the various web environments (Wilson et al., 2013).
opportunities for safe E Mental Health development…
E Mental Health holds great promise for mental health care now, and into the future. There are some gaps at present, and there is a significant need for ongoing research to develop practice-ready tools to contribute to a blended care delivery system (Fraser et al., 2016). Blended care includes elements of face-to-face and online or electronic components of clinical mental health care.
Mental health clinicians and researchers need to develop and refine their skills in the use of e health care technologies – especially in regard to web-based tools, apps and social media (Wilson et al., 2013). Encouragingly, students in the health professions indicate that they are likely to have a strong grasp of electronic health care and information transfer because they bring pre-existing web-savvy skills to their pre-qualification studies (Usher et al., 2014).
Governments and funding bodies increasingly anticipate the incorporation of strategic E Mental Health care into health service delivery systems, because it aligns with economic business plans and population distribution plans (Department of Health., 2015; E-mental health strategy for Australia, 2012; European Commission, 2012).
- E Mental Health is not new, but it is expanding at a rapid pace, driven by consumer demand and heath service financial constraints to deliver more services with limited budgets
- Three main avenues exist for E Mental health: Voice/ text; video; and Web 1 & 2.
- Opportunities exist to build safe E Mental Health into the future as research and development collaborate with willing practitioners to create a evidence base to support best practice in the E Mental Health field.
Alkhaldi, G., Hamilton, F. L., Lau, R., Webster, R., Michie, S., & Murray, E. (2016). The effectiveness of prompts to promote engagement with digital interventions: a systematic review. Journal of Medical Internet Research, 18(1), e6. doi:10.2196/jmir.4790
Australian Commission on Safety and Quality in Healthcare. (2016). Safety in E Health. Retrieved from http://www.safetyandquality.gov.au/our-work/safety-in-e-health/
Bailey, J., Murray, E., Rait, G., Mercer, C., Morris, R., Peacock, R., . . . Nazareth, I. (2010). Interactive computer-based interventions for sexual health promotion. Cochrane Database of Systematic Reviews, 9(CD006483). doi:10.1002/14651858.CD006483.pub2.
Bissell, D. (2013). Virtual infrastructures of habit; the changing intensities of habit through gracefulness, restlessness and clumsiness. Cultural Geographies, 0(0), 1-20.
Brusse, C., Gardner, K., McAullay, D., & Dowden, M. (2014). Social Media and Mobile Apps for Health Promotion in Australian Indigenous Populations: Scoping Review. J Med Internet Res, 16(12), e280. doi:10.2196/jmir.3614
Department of Health. (2015). e-Health. Retrieved from http://www.ehealth.gov.au/internet/ehealth/publishing.nsf/content/home
E-mental health strategy for Australia. (2012). Canberra: Commonwealth of Australia Retrieved from http://www.health.gov.au/internet/main/publishing.nsf/Content/D67E137E77F0CE90CA257A2F0007736A/$File/emstrat.pdf.
Elsom, S., Sands, N., Roper, C., Hoppner, C., & Gerdtz, M. (2013). Telephone survey of service-user experiences of a telephone-based mental health triage service. International Journal of Mental Health Nursing, 22, 437-443.
European Commission. (2012). eHealth Action Plan 2012-2020 – Innovative healthcare for the 21st century. Retrieved from Brussels: file:///Users/rhondawilson/Downloads/eHealthActionPlan2012-2020.pdf
Fox, S., & Duggan, M. (2012). Mobile Health 2012: Half of smartphone owners use their devices to get health information and one-fifth of smartphone owners have health apps Retrieved from California Health Care Foundation: E Mental Health.docx
Fraser, S., Randell, A., DeSilva, S., & Parker, A. (2016). Research Bulletin: E-mental health: the future of youth mental health? Retrieved from Orygen Youth Health: https://orygen.org.au/Our-Research/Research-Areas/Online-Interventions-and-Innovation/Orygen-Research-Bulletin-E-Mental-Health.aspx
ICT Data and Statistics Division Telecommunication Development Bureau Geneva Switzerland International Telecommunications Union. (2012). Mobile cellular subscriptions per 100 inhabitants, 2001-2011 (Excel Spreadsheet) Retrieved from http://www.itu.int/ITU-D/ict/statistics/material/excel/2011/Mobile_cellular_01-11.xls.
. from Telecommunication Development Bureau Geneva, Switzerland: International Telecommunications Union. http://www.itu.int/ITU-D/ict/statistics/material/excel/2011/Mobile_cellular_01-11.xls.
. myCompass. Introductory video. (2010). In B. D. I. m. program (Producer). Australia: Black Dog Institute.
Nancy Lublin: Texting that saves lives. (2012, April 2012). TED talks. Ideas worth spreading. Retrieved from http://www.ted.com/talks/nancy_lublin_texting_that_saves_lives.html
Proudfoot, J. (2013). The future is in our hands: The role of mobile phones in the prevention and management of mental disorders. Australian and New Zealand Journal of Psychiatry, 47(2), 111-113.
Queensland Health. (Producer). (2013, 7 March 2013). Telehealth. Retrieved from https://www.facebook.com/notes/queensland-health/telehealth/379845328790222
Statewide telehealth services. (Writer). (2013). Extending the reach of clinical health services throughout Queensland . In Q. health (Producer). Australia: Queensland health.
Usher, K., Woods, C., Casella, E., Glass, N., Wilson R. L., Mayner, L., . . . P., I. (2014). Australian health professions student use of social media. Collegian, 21(2), 95-101. doi:10.1016/j.colegn.2014.02.004
Wilson R. L., & Usher, K. (2015). Rural nurses: A convenient co-location strategy for rural mental health care of young people. Journal of Clinical Nursing, 1-11. doi:DOI: 10.1111/jocn.12882
Wilson, R. L., Ranse, J., Cashin, A., & McNamara, P. (2013). Nurses and Twitter: The good, the bad, and the reluctant. Collegian(0). doi:http://dx.doi.org/10.1016/j.colegn.2013.09.003
Recovery quilts – collaborations of caring
I have a colleague and friend who is unwell at the moment. It is an awful feeling when someone you know is really very sick – and finding ways to help, and showing you care makes all the world of difference…to them and you!
This blog aims to highlight one way to draw together the social capital among small groups of friends, colleagues, family… whoever… for the purpose of collaborating in the development of a quilt gift to give to a person who is recovering. Bringing together a group of people to collaborate in building a quilt as a gift, is one way in which it is possible to develop a tangible expression of care, concern and hopefulness for recovery. Quilts convey both a physical and an emotional warm, a closeness and some comfort, and the expression of these elements in a gift of a quilt can carry with it some positive affect to enhance recovery. I have written a paper about how this has been done in the past – you can read more about some research about recovery quilting here.
Wabi-Sabi – imperfect is beautiful!
A collaborative quilt doesn’t need a great deal of sewing skill or expertise, and creating a project that non-sewers can be included in is possible. The quilt doesn’t need to be stitch-perfect. In Japanese culture there is a concept of Wabi-Sabi – imperfectly beautiful! I think collaborative care expressed in a quilt is an ideal match to the wabi-sabi concept. A little bit of guidance and some inspiration – everyone can have a go and contribute something, without the expectation of being perfect. A relaxed and inclusive way for everyone to work together. I have contributed to a few collaborative quilts – and in my experience, the beauty really is in the varied interpretations and inspirations of each contributor. The meaningfulness that is sewn into each block is a great way to ensure variety. And, with this level of flexibility – it works!
What is needed:
- Someone that can lead the sewing and guide beginners (someone needs to have little bit of knowhow… but, you can manage with just a ‘little’!)
- Fabric for the top – avid quilters will have a stash! (they can’t help themselves!) Ask them to contribute some… or use some reclaimed/ vintage fabrics from an op-shop. Or – buy a ‘jelly roll’ (cut strips of fabric) from a patchwork or fabric shop. What ever you do to collect your fabric – you will need to give it to your quilting collaborators in a ready made/cut blocks. A block will be easiest to work with if it is a square shape. The size doesn’t matter – but do make sure that all of the blocks are exactly the same size. Here is a free pattern if you need one! And some youtube guidance if that helps!
- Middle – batting. Go to a quilt/ fabric shop and buy the quantity you need. You don’t have to have batting… you might prefer to use a cosy backing instead (eg fleece or chenille). The batting is best new – choose a wash and wear type. I prefer bamboo or cotton.
- Backing – can be a reclaimed sheet, tablecloth, curtain or bed spread (op-shop again!) Or – you can buy some plain fabric for the back.
- Distribute the blocks to the collaborators and encourage people to have a go! The more that contribute – the more beautiful the diversity!
What to do with your block:
Here is a list of my favourite ideas about what to put on your block…. it is only a sample of ideas shared (and borrowed) to stimulate your own creativity! Pinterest is a great source of inspiration and has lots of tutorials and patterns to get you started if you need some! Remember to leave 1 1/2cm border around the edge so the blocks can be sewn together.
- Doilies are a great and simple edition to a block. They can be easily hand sewn onto a block.
- Buttons sewn in a corner or in a shape, eg bird or heart.
- Crochet a mandala or a granny square and sew it on your block.
- Crochet a button!
- Use a simple stitch to make a monogram or to stitch a shape design – eg a heart, star, or just straight or spiral lines.
- Applique – a fancy word that means sewing one layer of fabric over another. You can use fusible iron-on webbing to stick the fabric together and then blanket stitch around the edge of your shape, but you don’t have to.
- Use floss/ embroidery thread to embroider some stitches…. as fancy or as simple as you like. A cross stitch animal, tree, or design in a corner of your block for example.
- Use some yarn or ribbon to make a design on your block and then ‘stab’ stitch it in place to stabilise your design.
- Cut some felt flowers and sew a button in their centres to stabilise the flower on the block. Leave the petals free or blanket stitch them in place. Or make some felt birds!
- Cut a range of various sized circles of fabric or felt and layer them to look like flower petals – secure with a centre button or bead.
- highlight some features in the block fabric with coloured stitches or buttons or ric-rac
- Select a variety of stitch techniques
- Make some tiny pom-poms – or buy pom-pom ribbon – cut, arrange and sew in place as a bunch of balloons in a design.
- Use ribbons or ric-rac to make a rainbow, garden or decorative lines, curves for designs
- machine embroider a design
- Black thread embroidery – feathers
- Add beads and sequins to your block or sew a trinket, mirror disc or charm in place.
Here are some links to some craft sites that might be sources of creative inspiration for some!
Building and giving a quilt together
Relationships are strengthened, emotions are shared and comfort is provided in undertaking this type of collaborative activity. All are stronger together. Have fun making and giving quilts in collaboration with others – a burden shared is a burden halved! And above all…. wabi-sabi! Imperfect can be beautiful – so enjoy the journey what ever your skills might be! Collaborative caring…
I have a few quilting, embroidery and textile artist brains trust that I turn to for ideas, inspiration, tutorage and rescue when needed. Thank you for your encouragement, generosity and skills! When I grow up – I hope to be as expert and generous as you all are in your quilting, embroidery and textiles! xo
A CONVERSATION TO BUILD MENTAL HEALTH RURAL RECOVERY IN A CHURCH SETTING: A STORY ABOUT A PATCHWORK QUILT, A YOUNG PERSON & A MENTAL HEALTH NURSE
I am presenting this poster at the 39th International Conference of Australian Mental Health Nurses,
Pan Pacific Hotel, Perth, Australia
…you can follow along on Twitter at #ACMHN2013
A CONVERSATION TO BUILD MENTAL HEALTH RURAL RECOVERY IN A CHURCH SETTING: A STORY ABOUT A PATCHWORK QUILT, A YOUNG PERSON & A MENTAL HEALTH NURSE
Rhonda L. Wilson, RN BNSc MNurs(Hons) PhD candidate, School of Health, University of New England, Armidale NSW Australia
Introduction Mental health nurses in collaboration with churches can contribute positively to the mental health of communities.
This project shows how mental health nurses who already established in their dual roles as church member & mental health nurse, can contribute in a unique way to the mental health of individuals within their usual church setting. Social capital within churches can be harnessed to promote mental health helping within smaller groups & to reduce the stigma & isolation often experienced by people and families with mental health problems.
While a young woman was in hospital receiving acute mental health treatment over a period of weeks, a group of 16 church people produced a patch work quilt to give to the young member of their church who had experienced an acute episode of mental distress. The project was jointly led by a mental health nurse & an expert patchwork quilt maker. This collaboration capitalized on the skills within the small group, & combined them in such a way as to develop a unique avenue of support to the young woman quilt recipient. Church community members were enthusiastically engaged with the quilt making process because it offered them an opportunity to come together & learn more about mental illness while expressing their concern & care towards the young woman experiencing the episode of mental health distress. The quilt recipient was able to be engaged in the community without the adverse impacts of stigma or awkwardness. Together, this promoted acceptance in both directions and enhanced mental health recovery potential and shared community.
- Provide a safe recovery environment for the young woman & to prepare the church community as a safe, stigma-free & supportive place to assist recovery.
- Convey care, comfort & support
- Raise mental health awareness about mental ill-health amongst church community members.
Nursing Social Capital
- Nurses promote health, well-being & recovery.
- Nurses are health & well-being social capital in their professional & community roles.
An expression of health & well-being social capital occurs within a church community setting.
- Nurses are health capital in rural churches for people with mental health problem
- Prevalence of mental health problems is higher in rural communities
- Rural communities have fewer formal mental health services.
Two people, a mental health nurse & a quilt maker planned the project together.
- •Fabric resources were donated by interested people, & the project participants were invited by word-of-mouth to group sewing sessions.•A snowballing of interest ensued as more people (including non-sewers) became involved.•At the first session, the mental health nurse led a short discussion about mental health awareness & a guided group conversation about the topic followed.•The quilt maker led a short workshop about the techniques that would be used to develop the quilt.•An eight-week time frame to complete the project was selected.•A theme was chosen which would resonate with the recipient & reconnect her to some personal successes she had achieved in the recent past, volunteering in Africa & Greece.
Post Project Survey Results
Ethics was obtained & an evaluation survey of project participants (n15) conducted using an anonymous online survey tool (survey monkey) to understand if the project had met its original goals.
Selected participant comments which reflect their experiences & aspirations about the project:
- •a quilt is a physical reminder that she is loved & valued.
- •It allows the recipient to not have to deal with many well meaning (but awkward) visitors. It is a visual & tactile reminder at the lowest of times (yet) offers physical comfort, & these are important aspects of the gift. The sense of unity that the quilt displays (many people working on it, but all put together) may also offer some comfort and remind the recipient of the power of community and their position within that, no matter her mental health.
- •Inspiration to press on with her life dreams.
- •Whenever she has & holds on to the quilt that she will not feel alone.
- •Strong sense of working together. Sense that people were ‘doing something’ to contribute to a solution.
- •The opportunity to express love by doing something tangible. Plus I like quilting!
- •I wanted to help, but didn’t know how.
- •How helpless I felt & how little I really know about mental health even though my own brother suicided many years ago.
- •It is a medical condition no different to a broken bone-that it needs care & needs to repair with time.
- •We all have down times – they are a part of life.
- •That it is good to talk about it – not push it under the carpet like it doesn’t exist.
- •The sense of the shared ‘journey’, the collective expression of love and care.
- •A beautiful, beautiful idea 🙂 wonderful bonding…
Discussion. What was learnt about mental health and quilting:
Project members were able to come together in such a way as to generate a recovery environment & to promote a public conversation about mental health matters in a supportive environment. They were able to transfer their internal motivation of helping, towards active practical helping, & to participate in a public conversation about mental health. These aspects are very important in the reduction of stigma about mental health problems & to help in the development of resilience & recovery in community groups and amongst individuals.
The shared journey of learning about mental health, being prepared to talk about mental health, & of contributing to a quality activity together, helped group members in their personal spiritual & mental health development & awareness.
Initially there was a shared awkwardness about mental health but conversations about mental health issues became easier over time, setting the scene for a warm, welcoming recovery environment for the quilt recipient to return to. A group environment developed where members were sufficiently brave to step beyond their personal comfort zones & learn new skills, either about mental health conversation, or about quilting. Both were equally confronting for some members.
The quilt recipient was presented with the quilt in a usual church service & after the mental health nurse had assessed the emotional safety of doing so with the quilt recipient. The quilt recipient was extremely appreciative of this moment & it opened the conversation about mental health & recovery more widely amongst the broader church community who were then able to contribute to the overall safe, warm recovery space amongst people who cared for her.
A brief project was envisaged as a local response to a mental health crisis for a member of small rural church. The unique social capital within the church community was utilized to assist the recovery of one person following a mental health crisis, & to create a stronger public conversation about mental health issues thereby reducing stigma. The partnership of a mental health nurse & an expert quilter, & their leadership of a small group were key elements in developing the project.
The outcomes of the project have been extremely positive & have yielded a professionally constructed quilt as a tangible mental health recovery resource, & developed a stronger affinity for caring for people with mental health problems within a small group. The project had its origins as an act of kindness & compassion but, by utilizing the social capital strategically, developed into a positive experience for the quilt recipient, quilt group members, & the broader local church.
This project demonstrates how the quilt concept was developed, and what can be achieved by a small group of people who are prepared to harness their collective skills towards improving grass roots community mental health on a small scale.