Mental health matters for microfinance

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>>Authored by Bobbi Gray, Research Director, Freedom from Hunger

First of all, a disclaimer. I am by no means a mental health expert. Like many, I’ve had my own experiences which have led to interests into the causes and impacts of mental health issues as well as the coping mechanisms we might use when we or someone we know suffers from a mental illness.

It’s Mental Illness Awareness Week, as you might know, and it has reminded me of a conversation that Josh Goldstein, vice president of economic citizenship and disability inclusion at the Center for Financial Inclusion at Accion, and I started a while back. A conversation that also led to an exchange of ideas on his blog post “4 interventions to help victims of trauma find hope and dignity” in which he summarized his remarks at the 8th Annual PCAF Pan-African Psychotrauma Conference held in Nairobi, Kenya. (Josh’s full conference remarks can be found here.) During this conference, Josh tried to answer the question of whether microfinance institutions (MFIs) can help victims of trauma who suffer from mental health disorders, such as post-traumatic stress disorder (PTSD), to find hope and dignity through self-employment.

In his post, Josh suggests steps to be taken by our sector to be inclusive of those suffering from mental health disorders. In this post, I’ll address two of those steps:

  1. More linkages between mental health providers and MFIs can take place such that people have access to financial services and business and financial training.
  2. Create a set of global standards and indicators for MFIs and other financial service providers to follow that will establish the importance of and offer guidance on serving PTSD survivors and other persons with psycho-social disabilities.

While Freedom from Hunger works actively with our partners to link their clients to health service providers through our integrated approach, I can’t speak yet to having a lot of success on Josh’s first step above — i.e. the specific linkage to mental health service providers. Though this doesn’t mean there aren’t already bright spots. This (really interesting) Freakonomics podcast discusses how cognitive behavioral therapy (CBT) and cash transfers are being combined for child soldiers in Liberia. Spoiler alert, CBT plus cash transfers leads to men staying out of trouble, compared to getting only CBT or only a cash transfer.

On Josh’s second point, regarding the need to start by understanding and measuring the extent of psycho-social disabilities, we’re just dipping our toes in the water.

In the paper we produced called “Healthy, Wealthy, and Wise: How Microfinance Can Track the Health of Clients,” in which we share experiences in selecting and pilot-testing our Health Outcome Performance Indicators (HOPI) among MFIs, some of our initial testing around mental health indicators was limited and was initially driven by the acknowledgement that consequences of domestic violence should be better understood and tracked.

Since the publication of that paper, we’ve conducted research in Burkina Faso with 46 women that we followed over a 7-month period to better understand resilience. We tried to look at resilience holistically and included “attitude” questions in all 10 surveys we conducted. One survey focused entirely on attitudes and perceptions of one’s life. We pulled heavily from research conducted by Johannes Haushofer, who is a professor and researcher of psychology and public affairs at Princeton. He took variables from a World Values Survey and compared them to poverty status.

In the research in Burkina Faso, we compared self-perceived resilience status (i.e., “Based on what you consider to be a resilient household, do you believe your household is resilient?”) to a series of indicators, approximately 14 of which were attitude/perception indicators. We found that those who considered themselves resilient were also likely to report feeling supported, hopeful, capable of meeting one’s financial obligations, trustful of others, and not living one’s life “day to day.” They reported that they would try anything to improve their life. (This research will be available by the end of October through CGAP).

These indicators are just one slice of mental health — but it is a starting point. We have Haushofer’s research as well as our simple forays into developing the HOPI, which we think MFIs can use to measure and monitor client status. Given this headway, I think we all can have a greater appreciation of the power that positive or negative mental health can have on a person’s productivity and their likelihood of success with the types of financial tools we can provide.

For microfinance and beyond, I think we have the research we need to argue that mental health matters. (See this recently published paper in the Lancet regarding mental health research in Europe.) The direct costs (i.e., healthcare costs and productivity losses) and the indirect costs (i.e., wage and productivity losses of caregivers and family members) can be significant.

And mental health matters even if we’re not distinguishing between people with diagnosed mental health impairments versus the mental health challenges poverty often creates. In fact, in the book Scarcity by Sendhil Mullainathan and Eldar Shafir, we are challenged to recognize this. They explain how “scarcity captures the mind. The mind orients automatically, powerfully, toward unfulfilled needs. Scarcity…changes the way we think. It imposes itself on our mind. The consequence of having less than we want is simple: we are unhappy.”

I think we’ve all had periods of our life in which we can relate to what mental distress feels like. Your mental bandwidth is limited, and its hard to feel hopeful when you’re going through a trial. I wonder if we should assume that the starting point is that all clients we serve could benefit from mental health support given what we know about the psychology of poverty. Everyone deserves a financial product or process that helps them through life’s short and long-term crises — whether it’s a purely economic crisis, a visible health crisis like dealing with cancer, or a mental health crisis that has no obvious cause.

Obviously, this is easier said than done. But, over time, I’ve come to really value and appreciate what the mental health and psychosocial indicators can tell me about a person’s life. Even if a person’s poverty status hasn’t changed but their belief that their life is better and more manageable, I can see where that can be considered success.

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