Scheunemann on strengthening Lesotho’s mental health services and awareness

In this interview with Newsday, Ann Scheunemann, a dedicated Peace Corps volunteer-turned-psychologist, discusses her ongoing journey with the Lesotho-Boston Health Alliance (LeBoHA) to advance mental health care in Lesotho. From her initial volunteer work to conducting a needs assessment and situational analysis, Scheunemann shares insights on the critical challenges facing mental health services in the country, the importance of integrating mental health into primary care, and her vision for a future where mental health resources and awareness are widely accessible across Lesotho.

Newsday: Your work in Lesotho spans from your time as a Peace Corps Volunteer to your current role with the Lesotho-Boston Health Alliance (LeBoHA). What inspired you to return to Lesotho after completing your PhD in Applied Social and Community Psychology?

Ann Scheunemann (AS): Returning was something I had always wanted to do. I had completed my undergraduate degree before entering the Peace Corps, with the intention of pursuing a career in medicine. My experiences in the Peace Corps and Lesotho were formative and redirected my career trajectory. I left wanting to pursue a degree in mental health, which eventually led to obtaining a PhD in Applied Social and Community Psychology. I was fortunate after graduating to be offered a postdoctoral position at Boston Medical Center, which allowed me to return to Lesotho and work with the Lesotho-Boston Health Alliance (LeBoHA), on a needs assessment and situational analysis of mental health in Lesotho.

Newsday: Since January 2023, you’ve been conducting a situational analysis and needs assessment of mental health in Lesotho. Could you walk us through some of the most significant findings from this study so far?

AS: LeBoHA’s work in providing the Family Medicine Specialty training program and medical internship has underscored the need to improve mental health services. This background inspired the study, which aims to inform the integration of mental health into healthcare services and the development of mental health training programs in Lesotho. The study is broad and was initiated with the goal of better understanding the landscape of mental health in Lesotho, from the perspective of health workers, mental health workers, and adult community members. As such, it is meant to scratch the surface of the state of mental health in Lesotho and provide direction for future research and initiatives to improve mental health and care. The study asked participants how they would define mental wellbeing and illness, signs and symptoms of mental distress, adversities and resilience resources that may impact mental health, and recommendations for improving mental health and care. Additionally, participants were asked these questions with regard to children, adolescents and young adults, adults, and older adults, because at different developmental stages people face different adversities and experiences the world differently, which impacts mental health. One major finding is a lack of material and human resources to support mental health care. There are few mental health professionals in the country, particularly outside of Maseru, including child mental health experts, clinical psychiatrists, psychiatric social workers, and psychiatrists. Another finding is that many of the challenges people in Lesotho are facing which may impact mental health are socioeconomic, like interpersonal conflict (including inter-partner violence and child abuse), wealth disparity, and unemployment. A positive finding is the number of participants asking for more and ongoing information about mental health and care. People wanted to know more, and recognize that mental health is complicated, and more than a single meeting or workshop is required to learn about mental wellbeing and illness. This was a particularly exciting finding to me, because it presents a great opportunity for improving mental health – increased mental health promotion activities in schools (from preschool onward), in communities, and in health facilities.

Newsday: Mental health is often stigmatised in many societies. Based on your research, how would you describe the general perception of mental health in Lesotho? Are there any cultural or societal barriers to seeking care that you’ve identified?

AS: Based on participant responses, mental health is stigmatized in Lesotho. Participants noted that mental illness was still associated with witchcraft sometimes – people with mental disorders were believed to be bewitched. This could also impact older people, particularly those with dementia, who were accused of bewitching others. Regarding children, mothers could be blamed for a child’s mental illness, leading to stigma of the family more broadly. Participants also noted that signs of a child’s distress could be misinterpreted as a child just being naughty. Participants also noted that adults were hesitant to seek care at mental health facilities, out of fear they would be seen and judged. Many of these barriers are common across the world.

Newsday: You’ve mentioned that the findings of your assessment will inform future directions for strengthening Lesotho’s mental health systems and services. Can you share some potential strategies or interventions that may be implemented based on these findings?

AS: The findings in this study do align with findings from other countries, and there are evidence-based strategies developed in other countries in sub-Saharan Africa and beyond, that I think could be successfully adapted to Lesotho’s context. Parenting for Lifelong Health, for example, is an intervention from South Africa that teaches positive parenting, mental health for carers, and economic empowerment. An adapted version was piloted in Mokhotlong a few years ago. The Friendship Bench out of Zimbabwe is another intervention that may be effective here. There are a lot. There is a lot of potential for mental health promotion in schools, so that from a young age people are aware of strategies to care for their mental health. Promotion and prevention are very effective strategies for maintaining mental wellbeing. Increasing the workforce and training more mental health professionals across disciplines as it is concerning that Lesotho does not have psychiatrists.

Newsday: In addition to your research, you’re also working with LeBoHA’s Family Medicine Specialty Training Programme to improve mental health care provided by family medicine specialists. How important is it to integrate mental health training into broader healthcare programs in Lesotho?

AS: Very. We often talk about mental and physical health separately, but they are not. We are one person, and our mental and physical health impact each other. Mental distress can lead to or worsen physical health, as stress impacts diet, exercise, and physiology. Physical health conditions can also impact mental health, particularly depression and anxiety. There is also a lot of evidence that childhood adversities that impact mental health can have lifelong consequences and are linked to poorer physical health outcomes in adulthood, and well as adverse mental health outcomes. An added layer is that we are not isolated beings; our wellbeing is also impacted by the family and friends around us. This is where a focus on patient- and family-oriented care is essential in healthcare programs. Loved ones can be a source of stress, as the study participants noted when discussing interpersonal conflict. But they can also be a great support for mental and physical health. Incorporating this into healthcare programs in Lesotho can be very beneficial. This is where family medicine comes in. LeBoHA has been offering Family Medicine Specialty Training in Lesotho since 2008 and has successfully produced a considerable number of family physicians. These doctors serve in district health management teams and hospitals across the country. Family physicians are primary care specialists dedicated to providing healthcare for individuals and families, regardless of age, gender, disease, or affected body part. They consider not only the health status of the individual but also the medical history of the entire family. Their approach emphasizes all aspects of healthcare, including mental illness prevention and mental health promotion. Therefore, it was essential to collaborate with family physicians to fully integrate mental health services into the curriculum and healthcare system.

Newsday: Mental health infrastructure is a global challenge, but particularly so in developing countries. From your perspective, what are some of the key areas where Lesotho’s mental health system needs strengthening, and how does it compare to other countries?

AS: According to the World Health Organization, Lesotho has a below-average number of mental health workers. A study from Lesotho which was published a couple years ago found a lack of mental health workers as well. The country currently does not have a psychiatrist, has few clinical psychologists, and needs more mental health workers across all disciplines – psychiatric social work, child psychologists and psychiatrists, school psychologists and counsellors, and psychiatric nurses, to name a few. Lesotho also has challenging infrastructure and terrain, which makes accessing mental health care difficult for those who need it. Services in remote areas, particularly in the highlands, are severely limited because of this. And a lack of human and material resources like transportation makes it difficult for mental health workers to get to remote communities. Lastly, I have mentioned schools before. Mental health care and education does not need to be only the purview of the health system – schools can play a role, employers can play a role, other government institutions can play a role. Mental health affects all aspects of our lives, and so can be approached from different aspects of our lives.

Newsday: You’ve presented your findings in multiple forums in Lesotho and will soon present at an international conference. How have these presentations been received, both locally and internationally? Are there any recurring themes or feedback that have stood out to you?

AS: I haven’t presented internationally yet, but within Lesotho I think there has been a lot of interest. Many of the forums in which I have presented have corroborated my findings, which is great. I think a lot of the feedback is that more resources are needed to begin tackling the problems that I identified in the study, and that health workers, mental health workers, and communities have been observing for years.

Newsday: Having lived in Lesotho for several years and now working on such a critical project, how would you describe the progress Lesotho has made in addressing mental health challenges since you first arrived as a Peace Corps Volunteer in 2007?

AS: I honestly can’t speak much to the mental health system of Lesotho when I was a volunteer. My memory is that the primary focus of the health system at that time was understandably HIV. I do know that I saw and worked with many adults and children who had experienced trauma, and the system seemed overwhelmed an unable to serve the needs of the population. There does seem to be increasing awareness of mental health promotion and care as a priority in Lesotho now, which as a psychologist I find exciting.

Newsday: Lastly, what are your hopes for the future of mental health care in Lesotho? What would you consider a major milestone or success in the next few years?

AS: I am hoping that the increased awareness of mental health promotion and care translates to action, like some of the suggestions I made above: increased training and employment of mental health professionals across disciplines; interventions to improve care, particularly in remote locations with limited access to services; and increased mental health promotion and education in schools and communities. In the next few years would love to see one psychiatrist in Lesotho, Basotho doctors training to specialize in psychiatry, an evidence-based intervention like the Friendship Bench being intensively piloted with ongoing support, and increased mental health education in schools.