Making mental health matter

On not-so-good days, Prof Xanthe Hunt has been known to dip into her handbag for a square or two of dark chocolate — the stuff with the extra-high cocoa content.

Chocolate is what she’d spend her last R100 on, jokes this psychologist, the mental health lead at the Africa Health Research Institute (AHRI) and an associate professor at Stellenbosch University (SU). That she has a personal stash of the sweet stuff to hand is a kind of mental health metaphor for her: It’s about knowing what you need to get through life’s inevitable dips, having access to it, and having it available when you need it.

This metaphor also extends to Hunt’s vision to transform South Africa’s public mental health services landscape, especially for the two vulnerable population groups that her work focuses on: the youth and people with disability. To begin with, she says, mental health services need to exist and they need to be more widely accessible. Next, services should be responsive and relevant to tailored needs.

Homing in on the apparently niche population groups of the youth and people with disability might seem like a luxury in a country that is yet to make mental health for all population sectors a priority. But, Hunt points out, it’s the youth who dominate as a population sector in Africa. Moreover, 80% of people with disability live in low- and middle-income countries, including those on our continent. This means that improving the mental health of these population groups actually makes for smart public health spending.

“I have always worked in the two streams of youth mental health and people with disability. After a while, you realise that there are overlaps. And these overlaps mean we can use our collective resources better. Regardless, we can’t sit back and do nothing just because we are resource or funding constrained.”

There are strategies and interventions that can be both low cost and effective. One, Hunt says, takes the form of task shifting. With this strategy, non-specialist tasks can be assigned to community health workers, teachers, and parents. This frees up specialists to concentrate on core needs. Hunt has also worked on digital strategies to deliver mental health services on online platforms. These resonate more with young people who are digital natives and extend the services’ reach to people in remote areas via virtual channels.

No mistakes for the poor

“I’m particularly interested in the social determinants of mental health. Things like poverty, violence, and eroded social networks (which are mostly undergirded by poverty) impact children and teenagers’ experiences and their ability to navigate the world.

“If you are poor, you don’t have the privilege of making mistakes — however developmentally appropriate they may be. So, for young people faced with these socioeconomic challenges, this means they have to set out to do everything perfectly. There is no room for wobbles and deviations, yet twists and turns in life are what you need as an adolescent busy figuring out yourself.”

Hunt speaks candidly about her own “rough time” being a teenager. She grew up in Pietermaritzburg and later Durban.

Her career too has held some detours and whims.

Her expertise lies in mental health, violence prevention and intervention, sexual health, disability, and social protection. She holds a PhD in psychology from SU and has postgraduate training from both Harvard University and SU in epidemiology, biostatistics, and research methods.

A less known fact is that she also holds an honours degree in journalism. She says she loved her stint working as a journalist, but didn’t end up staying in the media for long. There have also been fleeting moments when she considered teaching yoga as a career.

“A mental health strategy for the country has to include the creation of safety nets so that young people can kind of wobble and figure themselves out in a way that is appropriate, without having these incredibly punitive consequences because the environment can’t absorb this uncertainty.

“Sometimes, public health programming tends to occur in a bubble where you don’t always test them, so the approach can be very didactic, which doesn’t always work with teenagers,” Hunt says.

Human connection as the key

From the AHRI’s office in Somkhele, Mtubatuba, where she’s based, she talks about one of the first tattoos she got as a rebellious teen. It’s full of adolescent naivete, so much so that she can’t remember what she was thinking in giving it permanence on her skin.

She can laugh about it now, and has a special affection for this tattoo because of the new stories it has come to hold. Her point is that humans are often a hot mess of irrationality and impulse.

“There’s a kind of temptation, and a push from science, to believe that decision-making is evidence based. Fundamentally, though, the way people make decisions is highly idiosyncratic. But it’s also highly relational,” says Hunt.

It’s the relational bit that offers ways to place stronger human connections and trust at the centre of mental health wellness, especially for young people. She explains: “What we can do is work with children and teens to help them with things like developing emotional regulation, their capacity to pay attention, and their ability to form and sustain relationships. These things form the basis of what it will take for them to be more absorptive to life’s shocks. They are skills that undergird executive function and cognitive development, and they don’t fade out. Essentially, they are building blocks.”

Chronically curious to relate

Psychological preparedness to face uncertain futures is another strand of Hunt’s recent research. Young people are a key focus area because they live in a time of simmering unease over everything from high unemployment rates and generational debt to the stacked burden of the climate crisis and raging world conflicts. Added to this, their modern world is experienced through the lens of social media with its hyper-critical scrutiny and dizzying speed and volume of information, misinformation, and disinformation.

“When I’m working on programmes, I always ask how my 15-year-old self would have responded. I also believe in the virtues of being culturally incompetent. It helps you be empathetic but also allows you to enter a space in a position of not knowing and recognising your own privilege. Starting from this position can also be empowering,” she says.

Both in relating to teens and in her collaborative work with colleagues across the country, the rest of sub-Saharan Africa, and overseas, Hunt tries to apply this attitude of openness along with her “chronic curiosity”.

Leveraging networks for increase mental health

Hunt has worked as a consultant for the World Health Organization and with the London School of Hygiene and Tropical Medicine.

For her, creating stronger regional and global networks of researchers, health workers, and activists means leveraging collaboration — the power of the relational. It also means a larger community to help amplify the call to make mental health in low- to middle-income countries a health priority in its own right.

“We need to surface mental health so it’s not an issue that piggybacks on other healthcare needs. It should be the case that people simply deserve to be happy and to thrive.”

These networks also allow Hunt to lean on the research hubs that work with large mental health data sets and conduct longitudinal research. Building a statistical pillar for mental health, she says, is critical to creating a clearer picture of the impact of mental health challenges at an individual, household, and community level. She uses this data to develop and assess mental health programmes.

“When you have nuanced data and skilled analyses, you can better connect the dots. You can understand someone’s mental health challenges through a record that includes everything from their early childhood development to schooling and to issues at home and in the workplace. You’re also able to better predict things like suicide risks, to keep registers, and to make appropriate inventions.” Belgium, for example, has shown the life-saving benefits of using population health surveillance data in this way to reduce suicide rates, she says.

It may be a long time still before such interventions become a reality in South Africa, or even before mental health is considered a public health priority in the country. Better than most people though, Hunt understands that potholed paths and anxious turns are not reasons to change course. For her, there may be detours, likely more tattoos and definitely more chocolate, but she’ll keep moving forward because making mental health better demands it.