‘It’s a delicate topic’: Stigma, capabilities and young people’s mental health in post-conflict Colombia

ABSTRACT

Young people in Colombia present high rates of mental health problems, to which the country’s history of armed internal conflict contributes in complex ways. Mental health services in Colombia are fragmented, inadequate, and difficult to access for many. Young people’s help-seeking is often hindered by mental health stigma and/or poor experiences with services. This paper presents a thematic analysis of qualitative data from a mixed-methods study aimed at developing and testing a mental health intervention for Colombian youths. We draw upon theoretical lenses from scholarly work on stigma and Sen’s ‘capabilities approach’ to inform our analysis of interviews and group discussions with staff and young people involved in the state-funded human capital building programme ‘Jovenes en Acción’ (JeA). By illustrating how study participants talked about stigma, vulnerability, mental health services organisation, and the challenges of discussing mental health topics in a learning environment, we illuminate aspects of mental health support and anti-stigma interventions that might need enhancing. In particular, we suggest that more emphasis on ‘community competencies’ as complementary to and interrelated with individual competencies would strengthen young people’s individual and collective resources for mental wellbeing while being in line with the sociocritical principles of existing human capital-enhancing programmes.

KEYWORDS:

• Mental health
• stigma
• capabilities approach
• co-design
• Colombia

Introduction

The social and political history of Colombia contributes to the country having a very high incidence of mental illness. Colombia endured more than five decades of armed internal conflict leaving behind high rates of mental health problems among the Colombian youth in particular (Cuartas Ricaurte et al., 2019). Epidemiological studies in conflict-affected areas have shown high prevalence rates of anxiety (52%), depression (43%), and PTSD (19%) (Bedoya et al., 2019; Bell et al., 2012; Campo-Arias et al., 2014; Gómez-Restrepo et al., 2016; Richards et al., 2011), although there are considerable discrepancies in prevalence rates in the literature (Peevey et al., 2022). These high rates of often coexisting mental health problems intersect with high rates of socioeconomic deprivation and unequal or limited access to mental health services (Agudelo-Hernandez & Rojas-Andrade, 2023). Mental health is an important dimension of human capital formation, influencing young people’s education and labour opportunities. In this paper, we use theoretical lenses from Amartya Sen’s (1990, 2001) capabilities approach (CA) and CA-oriented scholarship to: 1, examine the ways in which staff and young beneficiaries of the state-funded human capital building programme Jóvenes en Acción (JeA, Youth in Action) discussed mental health and wellbeing, stigma and help seeking for mental and emotional distress; and 2, to identify interpersonal and community dimensions that ought to be considered carefully by all human capital supporting initiatives and wellbeing interventions in Colombia and worldwide. In doing so, we aim to contribute to the scholarship on stigma that calls for renewed attention to the structural factors implicated in its occurrence (Thornicroft et al., 2022; Tyler & Slater, 2018). To provide context for our analysis, in the following sections we first summarise established models of stigma and the key elements of CA as well as our rationale for drawing on these, and then outline the configuration of mental health services in Colombia and the essential features of the JeA programme and its Habilidades para la Vida (HplV, Skills for life) component, which represent the case examined here.

Stigma

Canadian–American sociologist and social psychologist Erving Goffman originally defined stigma (from the Greek word for a mark made by a pointed instrument) as referring to ‘an attribute that is deeply discrediting’ (1963, p. 3), and provided an in-depth and multi-faceted analysis of the relational nature of this ‘marking’ and of the experiences and acts of exclusion and discrimination it engenders. In the 60 years since its introduction, stigma – in its multiple configurations and implications in human interaction – has been studied from a variety of perspectives, with social psychological and health science accounts focusing on strategies to measure its predominance and impact (Gavan et al., 2022), and sociological and anthropological studies expanding the concept to include focus on cultural, social and material macro structures that enable stigma to function as power (Kleinman & Hall-Clifford, 2009; Link & Phelan, 2014; Tyler & Slater, 2018). With a particular focus on mental health and ‘self-stigma’, Corrigan and colleagues have developed and refined what is currently known as the socio-cognitive model of stigma (Corrigan & Rao, 2012). This focuses on the mechanisms via which a person becomes aware of a social stereotype (‘awareness’), concurs (to some degree) with it (‘agreement’), applies that stereotyping to themselves (‘application’) and experiences negative reactions such as loss of self-esteem and self-efficacy (‘harm’) (Corrigan & Rao, 2012). From a more distinctly sociological perspective, Link and Phelan (2001) have argued that stigma occurs when there is a convergence of four central components: social labelling of differences; linking of labels to undesirable characteristics via dominant cultural norms; creation of ‘us and them’ distinctions on the basis of said labels; and experiencing of status loss and unequal outcomes by labelled individuals. Further analyses of stigma have deliberately attempted to move beyond interpersonal interaction and explored the determinant effect on stigma of macro social structures such as class, gender, and ethnicity (Scambler, 2006) and argued that, rather than a fixed and easily identifiable entity, stigma is the shifting intersection of asymmetrical relationships and requires consideration of social positioning and intersectionality (Kusow, 2004).

There is a significant volume of scholarly literature exploring mental health stigma in Latin America and Colombia in particular (e.g. Acosta et al., 2021; Clay et al., 2020; Sapag et al., 2018; Vielma-Aguilera et al., 2021). It is well-known that mental health stigma is a factor in people delaying access to services (Campo-Arias et al., 2020). Historically, mental health stigma in Colombia has been perpetuated by neglect: mental health care often being an afterthought in national and regional programmes, plans and systems (Campo-Arias et al., 2014). In the case of conflict-affected areas in Colombia, the intersection of different labels and identities contributes to creating complex forms of stigmatisation. For example, Burgess and Fonseca (2020) explain how the label of ‘internally displaced person’ can add another dimension to people’s experiences of stigma and point out how ‘victimhood often intersects with additional categories of marginality – including indigenous identities and race’ (p.212). Recognition that stigma ‘takes shape in specific contexts of culture and power’ (Parker & Aggleton, 2003, p. 17) has contributed to attempts to ‘expand and reorient stigma’s theoretical lens to focus on meso and macro socio-cultural structures and power’ (Bonnington & Rose, 2014, p. 7; see also Tyler & Slater, 2018).

Here we draw on these latter orientations to stigma with the aim of examining closely aspects of participants’ views and experiences that tell us something about the complex interplay of structural and interpersonal barriers to better mental and emotional health for young Colombians. We adopt theoretical lenses from critical approaches to CA to make sense of the structural strengths and shortcomings our data points to, arguing that these lenses can draw attention to promising areas of development of mental health interventions in Colombia and elsewhere. We provide a brief overview of CA and the specific take on it we find useful in this context, below.

Capabilities approach-informed analyses of mental health in LMICs

The Capabilities Approach (CA) to the analysis of economic and social welfare was developed by Indian economist and philosopher (and Nobel prize winner) Amartya Sen in the 1980s and further developed by American philosopher Martha Nussbaum in the 1990s. Initially, the approach was developed as a means to transform traditional ways of analysing economic welfare, but it has been adapted and used in a range of different contexts, particularly in philosophy, sociology and human development. In a nutshell:

Instead of placing emphasis on utilities (i.e. access to resources such as income or assets), the CA focuses on promoting ‘the freedom that a person actually has to do things – things that he or she may value doing or being'. (White, Imperiale and Perera, 2016, p.18)

CA moves away from utilitarianism (i.e. a focus on the maximisation of happiness and the extent to which access to resources influences it) and highlights the importance for human development and economic analysis of exploring the social, economic and political structures that limit people’s freedoms – e.g. political freedom, economic facilities, social opportunities, transparency guarantees and protective security (Sen, 1999; Pressman & Summerfield, 2002). CA introduces and relies on a number of specific and interrelated concepts; while we cannot provide a detailed review of all of these here, we highlight entitlements, capabilities, and functionings as key ones (Pressman & Summerfield, 2002). Entitlements can be defined as ‘command over commodities’ (see Sen, 1982; Nussbaum & Sen, 1993), while capabilities are ‘a person’s real opportunities to do, and to be, in the context of a given society’ (Pressman & Summerfield, 2002, p. 430). The term ‘functionings’, finally, refers to the actual outcomes of what a person is or does (according to their capabilities). From a CA perspective, equity in capabilities – i.e. fair and equitable opportunities to be and do what one values – is necessary for people to participate fully in society (Pressman & Summerfield, 2002). In the last 10 years, there have been calls for CA-informed approaches to mental health, especially in the context of LMICs (White et al., 2016) and an acknowledgement of the growing influence of CA in the development of strategies aimed at enhancing mental wellbeing (White, 2020). In view of this, we interrogated our data to explore the extent to which CA may offer fresh insights into our participants’ accounts. More specifically, we drew upon the critical take on CA by authors with experience working with CA lenses to understand the circumstances of marginalised groups in LMICs. These authors acknowledge that achieving Sen’s capabilities in practice may prove difficult, ‘particularly in the absence of attention to psychological dimensions of personhood which enable individuals to utilise capabilities, including positive social identities, and socially receptive environments’ (Burgess & Fonseca, 2020, p. 214; Burgess, 2014). Contributing to more expansive framings of CA, Burgess and Fonseca draw attention in particular to ‘community competencies’ – i.e. social as well as psychological resources – and argue that these are ‘necessary for marginalised groups to effectively identify and respond to challenges in order to actualise capabilities and achieve freedoms and good health’ (2020, p. 214). Here the term ‘community’ does not necessarily refer to groups of people identified by place or diagnostic categories (around which public health programmes are often organised), but to groupings that individuals may define for themselves around action and practice. Drawing upon their earlier work in Africa (Burgess, 2012) and India (Burgess and Mathias, 2017), these authors identify four areas that are central to mental health ‘community competencies’:

1. promotion of mental health knowledge; (2) dialogue for the development of solidarity; (3) critical consciousness-raising to reflect on and engage with the structural and social causes of mental distress within safe spaces, and (4) opportunities to form partnerships to improve mental health (Burgess & Fonseca, 2020, p. 214).

In this paper, we draw attention to CA and ‘community competencies’ as useful analytical lenses that can help us establish a relationship between the individual and structural dimensions of mental wellbeing in the data we present. We return to this in our discussion but first, we provide an overview of mental health care in Colombia and a brief description of the government programme within which the study is situated.

Mental health services and psychosocial support in Colombia

The Colombian health system is made up of a large social security sector and a shrinking exclusively private sector. The former is the General System of Social Security in Health (SGSSS) with its two programmes, the contributory programme – or RC – enrolling salaried and pensioned workers and self-employed workers with income equal to or greater than the minimum wage, and the subsidised programme – or RS – enrolling all people without the ability to pay (Guerrero et al., 2011). Since the mid-twentieth century, there have been occurrences of guerrilla activity in various areas of Latin America as a form of social response to dictatorships. In Colombia, the guerrilla has translated into a long and complex internal armed conflict, which has – to date – affected over 9 million people (Unidad para la Atención y Reparación Integral a las Víctimas, 2023) and has resulted in, amongst other things, significant weakening of social and community structures and increasing inequities (Centro Nacional de Memoria Historica, 2013; Hernández-Holguín, 2020). It is well documented that the experience of violent and/or traumatic events as well as the social and geographical displacement caused by the conflict have significant effects on the mental health of people affected (e.g. Monsalve et al., 2021). While the Victims’s law 1448 of 2011 (originally meant to cover a period of 10 years and now extended through to 2031) created a programme to provide psychosocial attention (Programa de Atención Psicosocial y Salud Integral a Victimas – PAPSIVI in Spanish), a recent governmental evaluation showed that between 2013 and 2018 only 626,594 people of the 7,801,623 eligible victims received some form of attention (Minsalud, 2020).

Other policy initiatives such as Law 1616 of 2013 have aimed specifically at bridging the gaps in services for people with mental health issues; however, a 2018 literature review by Roja-Bernal et al. highlights that five years after the promulgation of Law 1616, inequity in mental health in Colombia is still a problem (Rojas-Bernal et al., 2018). This situation is aggravated by the lack of personnel and specialised centres for complex psychiatric care (Quijada et al., 2018). According to the World Health Organization (WHO) ‘around half the world’s population lives in countries where there is just one psychiatrist to serve 200,000 or more people’ (2022, p. 15) and in LMICs the median of all mental health care workers per 100,000 population is only 3.8 (2021a, p. 62). In our experience, it can be rather difficult to obtain clear and definitive figures for indicators of mental health care provision at a national level for Colombia (and other countries too). Although government-reported indicators of mental health provision at the national level do exist (e.g. WHO, 2021a; WHO, 2021b), these often fail to map onto the geographical distribution of multidimensional poverty (Gutiérrez López et al., 2020) or are aggregated by region in ways that limit granular understanding (e.g. Pan-American Health Organisation, 2023). With this in mind, we provide a table collating data from individual country profiles in the 2020 World Health Organisation mental health atlas for general orientation and context but recommend caution in consulting these (see Table 1).

Table 1 – Self-reported mental health data for Colombia and other countries – WHO mental health atlas 2020 member state profiles.

	Colombia	Ecuador	Peru	Brazil	Venezuela	Argentina	Bolivia	Chile	UK	USA
Total population	50,339,443	17,373,657	32,510,462	211,049,519	28,515,829	44,780,675	11,513,102	18,952,035	67,530,161	329,064,917
World Bank income group in 2019	Upper middle	Upper middle	Upper middle	Upper middle	Upper middle	Upper middle	Lower middle	High	High	High
Mental health burden in disability-adjusted life-years per 100,000 population	1461.2	1799.3	1606.5	2118.4	1626.2	1706.4	1842.1	1994.2	1959.2	2137.7
Age-standardised suicide mortality rate per 100,000 population	3.74	7.68	2.73	6.41	2.10	8.14	6.82	8.04	6.88	14.5
Government’s total mental health expenditure (as % of total health expenditure)	1.8%	1.2%	2.3%	1.6%	Not available	Not available	Not available	2.0%	Not available	Not available
Expenditure per person (USD)	4.66	0.1	3.95	1.69	Not available	Not available	Not available	9.88	Not available	Not available
Total psychiatrists per 100,000 population	2.5	0.42	3.5	3.7	1.1	14.5	0.4	8.5	13.7	Not available
Child & adolescent psychiatrists per 100,000 population	Not available	Not available	0.35	Not available	0.05	Not available	0.04	8.76	Not available	Not available
Facilities – inpatient beds in mental hospitals and psychiatric units per 100,000 population	29	4.8	3.6	6.8	2.7	26.9	1.6	8.5	Not available	Not available
Facilities – outpatients attached to hospital	7882	813	161	29	61	Not available	3	59	Not available	Not available
Facilities – community-based facilities	158	Not available	203	2667	121	Not available	Not available	385	Not available	Not available
Facilities – child and adolescent outpatients	Not available	Not available	159	256	4	Not available	Not available	117	Not available	Not available
Policy – stand-alone policy or plan for mental health	2018	2014	2018	2017	No	No	2009	2017	2019	2018
Policy – stand-alone or integrated policy for child/adolescent mental health	2018	2015	No	2002	No	Yes (year not known)	2009	2017	2019	2018

Human capital and the Jovenes en Acción (JeA) programme

Jovenes en Acción (Youth in Action) is a Colombian government programme on a national scale based on the offer of conditional cash transfers to support young people in their technical, technological and/or professional education. It is organised and coordinated by ‘Departamento de Prosperidad Social’ (Social Prosperity Department), which is the national government’s entity responsible for policies, plans and programmes relating to combating poverty, achieving social equity, and enabling the support of, care for, and social and economic reintegration of vulnerable groups and victims of the armed conflict (including the coordination of the ‘Comprehensive Care and Reparation Unit for Victims’, the ‘Colombian Institute of Family Well-being’, and the ‘Center for Historical Memory’). Young people aged between 14 and 28 and registered on at least one of the national registers of vulnerability and/or poverty are eligible to enrol on the programme. JeA was established in 2012 to promote social mobility and young people’s overall wellbeing. Central to the programme is the educational initiative known as ‘Habilidades para la vida’ (HplV – Skills for life).

The HplV training, which is central to young people’s learning around wellbeing and emotions and relationships, focuses primarily on supporting individual behaviours around self-management and self-development from a number of perspectives (in the context of education, employment, relationships and wellbeing). More precisely, the programme is organised around eight workshops on key areas of development (self-knowledge; leadership; conflict management; empathy; assertive communication; teamwork; resilience; decision-making) which are explored along the four key dimensions of ‘being (as inner self – "ser”)’, ‘having’, ‘doing’ and ‘being (as modes of operating – "estar”)’. The programme aims to:

… promote the transformation of each participant, through active participation in spaces of self-reflection and critical analysis of reality; of their knowledge, via participants’ recognition of their own knowledge and the building of new knowledge through interaction with others; of participants’ contexts and territories, across which they move alongside others and translate their potential into action. (Prosperidad social, 2022, p. 17)

The programme documentation states that this sits within a ‘socio-critical paradigm’ in which the development of individual criticality and collaborative knowledge production are central (Prosperidad social, 2022) and that it draws upon the principles of ‘human scale development’ (Desarrollo a Escala Humana) as developed by Chilean economist Max Neef and colleagues in the early 1990s (Max-Neef et al., 2006). By examining the ways in which JeA facilitators and beneficiaries referred to social aspects of mental health-related understandings and experiences, in this paper we illustrate why this programme may be an example of how an orientation towards the principles of the Capabilities Approach (CA) could enable more effective anti-stigma and community-strengthening action.

Materials and methods

This paper draws upon the qualitative component of a larger, ongoing study, aimed at developing and testing a mental health intervention for young people in Colombia, in particular those affected by the conflict (see project page – https://gobierno.uniandes.edu.co/es/investigaciones/proyectos-de-investigacion/mejorando-la-salud-mental-y-fomentando-el-capital-humano). The qualitative element of this study consisted of a participatory approach to the development of the intervention based on co-design principles and tools. This means we borrowed the approach of the early stages of an Experienced-Based Co-design (EBCD) cycle (Bate & Robert, 2007) to bring JeA staff and beneficiaries together to share views and experiences of mental and emotional health in young people and discuss the key features the proposed intervention should have. We explored JeA staff’s and beneficiaries’ experiences around and views of mental and emotional distress in young people first on an individual basis, then in separate groups (one with staff and one with beneficiaries) and in a mixed event (with both staff and beneficiaries). We carried out 18 one-to-one interviews (eight with JeA staff and ten with beneficiaries, see Table 2) and three group discussions with young people taking part in the JeA programme and JeA staff (two further group discussions with JeA beneficiaries took place for intervention refinement but are not examined in this paper).

Table 2. Characteristics of interview participants.

JeA staff		Young people (Age range 18-24)
Role		Involvement in JeA programme
Area manager	5	Current beneficiaries	7
Opportunity management worker	1	Recent beneficiaries	3
Follow-up worker	1
HplV module facilitator	1
Locality		Locality
Bogota’	5	Rural área 1	3
Rural áreas	3	Rural área 2	4
		Rural área 3
Gender		Gender
F	5	F	5
M	3	M	5
		Studies
		Undergraduate university programme	9
		Technical studies	1

Interviews were conducted either online via MS-Teams or over the telephone (in two cases where the Internet connection was unreliable) by SB, lasted between 30 and 45 minutes, were recorded and transcribed verbatim (by SB). SB carried out the first stage of thematic analysis (Braun & Clarke, 2006, 2022) of the interview transcripts manually, with regular discussion of early categories and themes with SD. The aim of this analytical phase was to highlight participants’ perspectives on any emotionally significant touchpoints in relation to mental and emotional wellbeing and/or distress. These early descriptive themes informed subsequent focus group discussions and the development of the intervention.

Two separate group sessions were held, one with JeA staff (GF1) and one with JeA beneficiaries (GF2). The first was attended by six members of JeA staff, five of whom had taken part in interviews; the second was attended by four beneficiaries, all of whom had taken part in an interview. Further insights from these discussions fed into a joint meeting (GF3) with both JeA staff and beneficiaries, which explored participants’ priorities for good mental health care and specific preferences for the development of an existing digital platform for this aim. This joint meeting was attended by five members of JeA staff (two of whom had been interviewed) and eight beneficiaries (only one of whom had been interviewed). SB was the lead facilitator for all the group sessions. Other members of the research team co-facilitated the breakout group activities of the last session. SD (who can read and understand Spanish) attended all group sessions to support SB and have a deeper connection with the data. All data was generated and analysed in Spanish with the primary aim of informing the development of a mental health intervention (findings in the study report, forthcoming). In this paper, we discuss the findings from further focused thematic analysis (Braun & Clarke, 2006, 2022) of the descriptive categories and themes already identified from interviews and group discussions. This analysis was carried out manually by SD, with regular discussions with SB, with the aim to explore how conceptual lenses borrowed from the sociological literature may contribute to relating the experiences of participants to theoretical perspectives that would be applicable in future mental health supporting interventions in Colombia and more broadly. This analysis led to the identification of critical approaches to CA as useful in illuminating possible missing ingredients in JeA and HplV, as we illustrate in the following sections.

The study was approved in Colombia by the Ethics Committees of Fundación Santa Fe de Bogota (CCEI-13269-2021) and in the UK by the Ethics Committee of King’s College London (HR/DP-21/22-22947). Participants were provided with a study information sheet and verbal consent was obtained at the beginning of the online/telephone interviews. The investigation team focused on letting participants know about their rights, that their participation was voluntary, that they could retract from participating at any point and that nothing would jeopardise their access to the subsidy. Only members of the research team had access to the data, which was securely stored on university servers. In this paper, all information that could identify participants (e.g. names, localities, job titles, etc.) has been omitted. Data analysis and discussion are interwoven in the ‘findings’ section below for a more cohesive presentation of our argument.

Findings

Mental health stigma and professional help

It was common for young people taking part in our study to refer to psychological and emotional issues as life experiences that in a way are not important enough to deserve other people’s attention and that are often overshadowed by more immediate issues around basic necessities. One young person said that other people’s responses suggested their needs were minor life challenges and this was enough to suppress willingness to share one’s struggles:

We don’t have much trust in others. In other words, sometimes we assume that people are going to think that our problems are insignificant, so we say like no, why would I tell them if they’re quickly going to say ‘no, look, but you’re drowning in a glass of water’. No, but if I tell them, they’re going to make fun of me. (B10, JeA beneficiary, interview)

These ‘others’ in our interviews included parents, other family members, at times friends, and the general public. Participants said that overall giving too much importance to emotional and psychological distress could be seen by others as a sign of weakness and seeking help as something that should be reserved for ‘mad people’ (sic.). For the young people in our study mental health stigma was clearly a major issue in Colombian general culture and heavily implicated in the ways in which young people experienced any mental distress and made decisions around whether to seek help and support for it. Another young person, for example, explained:

Sometimes we think, there are people who think, well, that the fact of seeking help, of having psychotherapy, of talking to the psychologist, that is for, it is for crazy people. There are really people who still think that going to the psychologist, that going to therapy is because one is very ill … (B4, JeA beneficiary, interview)

Referring to common preconceptions around help-seeking for mental and emotional distress, one young participant, called it social stigma:

It is not that the one who goes to the psychologist’s does so because they’re crazy’ – the social stigma’ (B8, JeA beneficiary, interview)

These ideas around public perceptions of mental and emotional distress were voiced by members of JeA staff too. Staff commented on young people not giving mental distress the importance it deserved, possibly due – at least in part – to preconceived ideas around the severity for which services are reserved. One participant stated:

They [young people] don’t see it as important, they don’t know they need it, they don’t know, so … (stops). ‘I don’t need a shrink [loquero], I don’t need a psychologist, I don’t need a psychiatrist’ they don’t see it, they don’t see it. (S3, JeA staff, interview)

This participant hinted at the fact that young people may not realise that professional support can help with distress irrespective of its severity, and talk of not needing to see a ‘loquero’ – a ‘shrink’, one who helps ‘crazy people’ (loco/a being Spanish for crazy), implying that they are not ‘crazy’. Another young participant suggested that there should be active efforts to change how people perceive mental distress and illness, because these perceptions have a clear impact on young people’s help-seeking behaviours:

Ensure that the population gradually understands that taking up any type of aid of this kind is the most normal thing, that you don’t have to wait for things to get worse in order to be able to, to make a move. But that as soon as you feel a little bad in some aspect of your life and want to offload, you can attend and it can be the most normal thing without feeling judged or anything like that. (B6, JeA beneficiary, interview)

The fear of being judged and labelled was clearly identified by one young participant as accompanying the experience of mental distress:

When we feel that something is not right, we are afraid of being labelled, afraid of being judged, of not finding someone who’d listen. (B1GF2, JeA beneficiary, group discussion)

Young people’s apprehension around being labelled and judged ‘crazy’ was referred to by members of staff too as having an impact on how they experienced and acted upon psychological and emotional difficulties:

They [young people] are afraid to speak, afraid of being called crazy, to be called depressed. Because when one is not managing emotions well and you, I, or anybody says: ‘Oh, and now, are you going to go crazy? Now what?’ … so they sort of start to label them and that is what they’re afraid of. (S7, JeA staff, interview)

JeA beneficiaries’ accounts suggested that social perceptions around mental distress, the associated stigma around all mental illness, and the direct experience of distress all contributed to young people feeling vulnerable and therefore often avoiding intensifying that feeling, for example by ‘hiding’ difficulties and/or trying to manage them or resolve them without anybody’s help:

It really depends on the situation, it is not very nice to feel vulnerable so one tries to hide things and solve them by themselves. (B9, JeA beneficiary, interview)

Feelings of vulnerability seemed to be particularly dreaded by young people, and this was voiced in group discussions too:

Everyone likes to maintain a good image. If I ask for help I’m going to show that I’m not well and I don’t want to be seen as vulnerable. (B5GF2, JeA beneficiary, group discussion)

Many participating JeA staff discussed the need for normalising conversations around mental health/illness and wellbeing support, but also highlighted that this normalisation should take place via channels that would prove appealing and genuinely engaging to young people:

Engagement, continuity, information, days dedicated to play, normalising emotions, a mental health fair, cultural activities with dance for expressing emotions, theatre to express symptoms, activities that are appealing to young people … (S6, JeA staff, interview)

In other words, any information or sensitisation effort should use more than one form of communication, be grounded in participation, and explore creative approaches to ‘role-modelling’ and/or practising emotional literacy. However, not only were these approaches lacking but the common reluctance to seek help for fear of judgement and stigmatisation was often made worse – and generally not helped – by mental health and support services that were not quite fit for purpose, as we will see in the next section.

The data analysis presented here shows that mental health stigma in Colombia remains a serious issue, directly affecting young people’s understanding of mental distress and their help-seeking behaviours. Some governmental strategies and campaigns aiming to dismantle this stigma do exist (see, for example, the Ministry of Health’s strategy for reduction of stigma 2014 – Rodriguez-Araujo, 2014; the OPS/PAHO – Panamerican Health Organisation – ‘Haz tu parte’ campaign 2022 – https://www.paho.org/es/campanas/haz-tu-parte); however, it is known that well-meaning campaigns can also have limited impact and unintended effects (Tyler & Slater, 2018). We noted earlier that the recent literature on stigma calls for sufficiently sophisticated understandings of it which include explicit analyses of structural stigma – i.e. the ‘societal-level conditions, cultural norms, and institutional policies that constrain the opportunities, resources, and wellbeing of the stigmatized’ (Hatzenbuehler & Link, 2014, p. 2). We suggest that programmes like JeA provide a context in which structural dimensions of mental health stigma are already referred to, although not explicitly or not in these terms. Participants’ reflections on the configuration of mental health services in Colombia, below, further support this claim.

Inadequate mental health services

We outlined in our introduction the overall configuration of mental health services in Colombia and the difficulties in establishing and reporting exact indicators for services and their uptake in different areas of the country. Participants in our study were critical of services; in particular, members of JeA staff commented on how the issue of mental health continued to be poorly addressed in the country, given the obvious impact on the life of the population:

I really believe that in this country, not much has been done on this topic [of mental health] and something that is so vital, so important, especially because every day we see how the population is more affected in matters of mental health. It has not been given the priority it deserves. (S1, JeA staff, interview)

Access to psychological support services is not very straightforward in Colombia (Rojas-Bernal et al., 2018; Zamora-Rondón et al., 2020) and waiting lists can translate into long delays, which can determine an overall loss of momentum in the relational dynamic of psychological support for the young person. The low number of qualified professionals (official figures report an average of 2.5 psychiatrists per 100,000 – see Table 1) can also mean longer waiting lists and that the time and attention dedicated to each person can be very limited. Poor experiences with support services can – and often do – prove off-putting and cause young people to try and deal with any mental health issues on their own. Participants in our study commented on the state of services, in particular in relation to inadequate workforce numbers, in specific districts:

In [name of local municipality] for example: there are only two psychiatrists. In [name of second local municipality] there is not even one and everybody is sent to [name of third local municipality]. These professionals tend to prescribe drugs and believe that this way they fixed the problem. There isn’t a quality service. (S4, JeA staff, interview)

Another factor contributing to making services ineffective was that they did not seem to cater to the needs and views of very different population groups. This point was highlighted by JeA beneficiaries as well as members of staff. One JeA facilitator explained:

I think one of the challenges is the diversity of the population we have. We have young people who are from minority ethnic groups, young people from the cities, young people from rural areas. And I think that this, well, it makes it difficult to support people, not only in the context of mental health, support even from the very moment the [JeA programme] workshops are held. (S2, JeA staff, interview)

The idea that diversity was not sufficiently addressed by support services was put forward by one young participant who commented from the perspective of somebody who identifies as belonging to a minority group:

… a victim of the armed conflict, take into account the special cases of the conflict. But not only that, to have a differentiated approach for the many communities in our country: indigenous, Afro, peasant, among others. (B7GF3, JeA beneficiary, group discussion)

Another member of staff highlighted that importance should be given also to the diversity of issues that people living in areas more directly affected by the conflict may face, including, among the most significant, substance misuse, sexual violence, murder, kidnapping, displacement, lack of employment opportunities and recent impact of COVID (S5, JeA staff, interview).

As the data presented in this and the previous section shows, JeA programme staff and young beneficiaries in our study articulated clear connections between individual (mental health knowledge, confidence, relationships with peers, etc.) and structural (poverty, displacement, access to education, paucity of services) factors relating to mental health stigma and to mental wellbeing more broadly. Staff and young beneficiaries from the JeA programme referred to the relationships between different levels of stigma, without necessarily using the language of ‘structural’ or micro–macro dimensions of stigma. In view of this sophisticated – although implicit – perspective on stigma, JeA and HplV are well positioned to function as platforms for work aimed at challenging and/or dismantling mental health stigma and at promoting supportive understandings of mental distress and help-seeking behaviours.

Despite this ideal positioning, the suggestion of a more deliberate focus on mental health in the context of the HplV workshops was considered inappropriate and quite risky by JeA facilitators. This area of young people’s lives – they argued – is the remit of mental health specialists and, given the particular circumstances of marginalised Colombian youths and the potential for terrible experiences of violence to have been part of their personal or family history, should not be approached in the absence of specialist expertise. We now turn to examining this theme in our data.

‘It’s a delicate topic’ – Discussing mental wellbeing in non-clinical spaces

JeA staff who spoke to us were very aware of the wider context in which young people’s mental distress occurred. They discussed the impact of lack of opportunities on mental health as well as the extent to which young people have ‘become used’ to this lack of opportunity, the influence of poverty and resource prioritisation in young people’s families and the broader issue of inadequate mental health services. Despite being directly involved in the ‘Skills for life’ programme, which – as we mentioned earlier – aims to equip young people with a range of self-awareness and social skills to enable them to live meaningful and rewarding lives, these members of staff considered themselves unequipped to discuss mental health in the sessions they facilitated. One member of staff, for example, was adamant that discussing mental health and illness could be done safely only with the help of specialised professionals:

It’s a delicate topic. In ‘skills for life’, we can share tips on mental health, but we should neither approach nor treat. For that to be possible, we would need clinical psychologists. Skills for life can be a preventive tool and also a space to guide young people to care pathways. (S3, JeA staff, interview)

Another JeA staff member (JeA staff S9) expressed a similar view and highlighted that Skills for life did not have the specific aim to support young people’s mental health. The central aim of the programme was to enable and support self-development, and although links could be made with mental and emotional well-being, the programme did not constitute the right space for further discussion on these issues. A few members of staff agreed that connections can be established only ‘transversally’ and one facilitator in particular (JeA staff S1) was especially concerned about the possibility of ‘re-traumatising’ conflict victims by discussing mental health issues in an unsuitable or even inappropriate context. The particular experiences of victims of the armed conflict were described as incredibly difficult to deal with:

One realizes, then, that really the young people, and above all, for example, this was a displaced young person. These areas of strong conflict can have many, many stories, many very strong experiences that one cannot even imagine. On one hand, you cannot imagine them, and also, really on the ground we do not have a route of attention, nor do we know how to approach it. (S1, JeA staff)

This perfectly understandable reluctance to explore individual mental health concerns in the context of group work with young people, suggests a focus on the more clinical aspects of mental distress among JeA staff. Although entirely appropriate, this biomedically-oriented and individual-centred reading of mental health and illness limits the scope of conversations around mental health with young people in that it overlooks those ‘structural’ determinants of experience – including the experience of emotional and mental struggles – the programme is oriented towards. This curbs, we suggest, the programme’s potential to contribute to mental health stigma reduction and young people’s proactive help-seeking.

All JeA staff we spoke to were very aware of the complex interconnections of different factors having a dramatic impact on young people’s mental health, especially as a consequence of more or less direct family exposure to the conflict. One participant explained:

[name of local municipality], which is in the [name of region] region, is an area that has been hit by the violence. Therefore, so many young people are displaced, they have had not very pleasant experiences, and everything that that implies – the social and economic aspects, the type of re-adaptation, having to move to a place that is not one’s own, to re-create one’s life, sometimes experiencing many difficulties. Additionally, this can generate an environment within the family of violence, intolerance, teenage pregnancies, consumption of psychoactive substances, and this also implies – already speaking of the other side – that the development of their academic, social, and family activities are totally chaotic. They are traumatized by all those sorts of facts. (S5, JeA staff, interview)

However, some participants suggested that approaching mental health in terms of exposure or non-exposure to the conflict had limited advantages and that there were so many influences challenging young people’s mental and emotional wellbeing that the issue needed an approach allowing for broader and more up-to-date perspectives. In this member of staff’s own words:

Look, this mental health issue affects them equally. Obviously those who come from the post-conflict have more, erm, causes of mental health issues because they suddenly experienced displacement, the loss of a loved one, rape, something, right? They have more, more grounds in the subject of mental health. But if we put things on a scale, young people are being affected in their mental health not only because of the post-conflict issue, but also because of the issue of social media, bullying, intrafamily violence. (S7, JeA staff, interview)

Another member of staff emphasised the importance, in supporting young people in the context of the JeA programme, of being able to tailor one’s approach to individual young people’s experiences and circumstances:

It is about accompanying, advancing, looking at what your strengths have been, yes? So that they can generate a better elaboration or re-elaboration of their life project. (S6, JeA staff, interview)

For this participant, the focus of support should be on building on the person’s strengths and accompanying their progress, thus enabling a perspective on existence that would entail some future-oriented purposiveness.

We suggest that the complexity-sensitive and tailored approaches our participants referred to would be perfectly compatible with sociocritically-informed discussions of emotional wellbeing, mental health, and stigma. These would not need to aim to elicit personal histories of distress from young people in the absence of adequate support – a scenario many of our JeA staff informants considered entirely inappropriate, as we have seen. Rather, they could explore the interrelatedness of the personal and the social, examining the ways in which structural factors affect individual freedoms and wellbeing. This is where a CA-sensitive strengthening of the programme and of related initiatives could help establish some missing links without in any way underplaying the importance of individual psychological and emotional awareness; in fact, in CA this individual dimension is central to people being able to utilise capabilities (see Burgess, 2014). We outline our practical suggestions in our conclusions, below.

Conclusions

The views expressed by young people and JeA staff members and presented above outline a complex picture in which mental health stigma, service organisation and the professional jurisdictions of education and healthcare all affect the extent to which Colombian youths are able to identify, understand and manage mental and emotional distress in their lives. The JeA programme and the HplV workshops within it are a particularly interesting case of social intervention shedding light on structural aspects of stigma as discussed by participants in this study. As a conditional cash transfer scheme, JeA specifically addresses economic deprivation as one of the structural conditions limiting young people’s access to professional education and the labour market. Although not targeting mental health stigma directly, the programme can be said to operate, at least in principle, at the level of structural forms of stigma relating to poverty, displacement, and marginalisation. In the context of JeA, the HplV component aims to provide young people with conceptual and practical tools to develop as self-aware individuals who can envisage their own life-trajectory, be resilient in the face of challenges and contribute to community and social projects (Prosperidad Social, 2022). Although the HplV workshops focus on individual acquisition of (personal and interpersonal) skills, many of which relate to individual psychological and emotional wellbeing, their overarching aim is very much one of structural reach.

We propose that, as an expansion and complement to individual development, a focus on capabilities and relationality in the context of emancipatory and/or therapeutic interventions would be desirable. We refer in particular to the CA-informed idea of ‘community competencies’ we discussed in the Introduction (Burgess & Fonseca, 2020). Many anti-stigma initiatives and campaigns target primarily the promotion of mental health knowledge by both encouraging social education programmes around mental health and illness and involving mental health service users in the development of resources that can provide insights into lived experiences of mental distress (Walsh and Hallam Foster, 2021). Education-based or mental health literacy-based anti-stigma campaigns are one of the most frequently used approaches to tackling stigma across the globe, and in LMICs in particular (Walsh & Hallam Foster, 2021). However, this corresponds to addressing only one of four key dimensions contributing to strengthening the ‘community competencies’ to which Burgess and Fonseca (2020) refer. We suggest that a focus on the other three areas of mental health ‘community competencies’ – i.e. solidarity, critical consciousness and partnerships – and their potential implication in individual experiences and structural determinants of stigma is an overlooked and potentially powerful complement to current practice. This focus could be easily embedded into existing initiatives aiming at supporting and strengthening human capital and has the potential to enhance their impact. For example, HplV explores themes of self-knowledge, empathy, and resilience in dedicated workshops, but, although locating itself in a sociocritical paradigm, it does not clearly address issues of power relations, civic participation, and/or social accountability. Resources and activities around solidarity and conscientisation (Freire, 1970) are in line with HplV sociocritical paradigm and could be relatively easily incorporated into the programme’s structure.

Although we make the case here for the Colombian context in view of the specific example we considered, the added focus we propose would be applicable to different socio-cultural environments and local constructions of ‘community’. We have argued the case here for the potential contribution of CA-informed lenses to human capital building initiatives like JeA in Colombia but we suggest these lenses can usefully contribute to critical approaches to mental health support and stigma awareness work anywhere. Following Walsh and Hallam Foster’s critical review of anti-stigma campaigns, we support a ‘contextualised understanding of the processes which sustain mental health-related stigma’ (2021, p.11) and a contextualised approach to undoing them. We argue that CA-informed perspectives and attention to ‘community competencies’ would be key tools for these contextualised approaches.

Acknowledgements

We are sincerely grateful to the JeA programme for taking part in the study this paper draws upon. In particular, we are grateful to the JeA beneficiaries and members of staff who took part in the interviews and group discussions discussed here. We are indebted to Alan Cribb at King’s College London, who offered precious insights and invaluable comments on drafts of this article.

Disclosure statement

The authors have no relevant financial or non-financial interests to disclose. The authors have no competing interests to declare that are relevant to the content of this article.

Additional information

Funding

This work was supported by Ministerio de Ciencia Tecnología e Innovación (Minciencias) under Grant C5 884-2020 and by the Economic and Social Research Council (ESRC) under Grant ES/V013173/1.