Paper by Bhargavi Davar, Swati Shinde, Deepali Deshmukh, Bart Bezemer, Lisanne van Eeden, Dharma Padalkar
Paper presented at the Panel, ASA14: Economic wealth and mental health, 20th June, 2014, University of Edinburgh
Introducing the Urban community mental health program, Pune (From 2004 until present)
Pune, a smaller Indian city in the west of India, has 550 ‘official’ slums, i.e., those which are provided a license by the local authorities. The license ensures that basic civic infrastructure, amenities like water and electricity, and government approved social services and schemes are provided. 42% of the Pune population (10 mn people) live in the slums. The Bapu Trust, Pune, works in a mere 2 of them, providing comprehensive urban community mental health services, serving a population of 50000 people, seeing around 450 clients every year. We see a wide spectrum of clients, from those with ‘stress’, ‘tension’, ‘pain’, ‘grief’ and other such transient experiences; to those in bottomed out states of health and mental health problems. The program started in 2004, when we provided psychotherapies and medication, built on a traditional client-therapist individualistic model. Other than being culturally dissonant, this model replicated the therapist-client power relationship, with net result of low client enrolment, high drop out and high relapse. The community and its resources were not enrolled into our program. Then we changed the program design.
Vision and design of the Bapu Trust program
The Vision of the Bapu program is, not just to ‘treat mental illness’ but to create ‘emotionally sustainable communities’. A matrix of non-formal and formal care services are provided, covering psycho-social aspects of cure, prevention and recovery; and social interventions for empowerment and inclusion. The program uses a wide set of psychosocial interventions provided by trained staff. Among the low income communities, we address the needs of marginalized groups by gender, caste, religion and social status (Davar 2012).
Non-formal care is the community-based foundation on which formal care is built up. Non-formal care includes a range of specific psychosocial services, including home visitors, peer support and support counselling, enabling neighbourhood care system, family counselling, interventions enabling social inclusion and stigma reduction. We are also active in providing awareness on mental health and well being. ‘Formal care’ includes a range of specific medical and psychosocial services, including comprehensive medical care, social care and rehabilitation, psychotherapies, arts based and body based therapies, and group therapies.
The Indian national mental health policy (National mental health program and plans of 1982, 2006) targets ‘severe mental disorders’. It was estimated in those days that 2-3% of people in any population will be affected by a variety of ‘severe mental disorders’. With the entry of the Global mental health movement (Patel, et. al. 2011; Prince et. al., 2007), and the intervention by World health organization through mhGAP (2011), those figures have increased phenomenally. It is proposed that upto 30% of populations worldwide may be suffering from a mental disorder requiring medical treatment. Further, since poverty, as found in LMICs, is considered a vicious and major determinant of mental illness, therefore, LMICs carry a huge unmet burden of mental disorders and stepping up medical care is the global policy recommendation.
1) Bapu Trust works in a low income community, where, in 10 years of intensive mental health work, we have never seen a single case of ‘bipolar illness’. We have not seen the expected number of ‘schizophrenias’ even after surveying about half the household in our working areas. We do see high levels of ‘stress’ ‘tension’, ‘pain’ and ‘traas’ (‘problem’ which can be further unpacked to have emotional components) caused by contingent socio-economic factors. We do see high levels of mood problems, alcoholism and psychological sequelae of domestic violence. Ofcourse, we see very high malnutrition though not so much hunger.
2) Contrary to our expectations that mental illness will be tremendously high in the low income communities where we work, many households seem to have resilience factors which buffer against psychosocial adversity, mental health issues and disabilities.
Our questions while working in the communities-
1. Why are we not finding ‘MI’ to the extent predicted?
2. Can we talk about resilience and well being of communities?
3. Are people in the slums ‘happy’? Do they ‘aspire’?
4. How do they hold together as a human society?
Based on a number of small, service linked research of the Bapu Trust, and our service reports and data (2010-2013), this paper argues that these questions can be answered in local terms but not in global terms. Slums have ‘personalities’ based on the variety of civic, historical, social, cultural, spiritual, economic and other aspects.
Some unlicensed slums (e.g. Ramnagar in Pune) did not transact on ‘social capital’ (McKenzie, 2008). In our search for a slum to work, we experienced that slum as hostile: Migrants living in outlying areas sharing only a functional bond of employment as construction labour, often without families or relatives, having to compete for local resources and where the neighbor is a competitor for scarce resources.
However, where we work, people are long term settlers with well established family, social networks and support systems. In our work we found that over 30 factors may influence the daily lives of communities: history; civic amenities such as water, electricity, road and transport; religious, sporting, social and cultural spaces; access to development including educational, occupational, health care and other social services. It is a ‘well to do’ slum though poverty is widespread!
We figure that among other factors, bonding and binding social capital is a protective factor for people from psychosocial distress and disturbance. Social capital can include concepts of support, safety and trust, belonging and reciprocity (Welsh and Berry, 2009). Where we work, we have found linked factors that may facilitate social capital and psychosocial resilience: Participation in organized groups, altruism, historical factors / lineage encouraging social cohesion, aspiration for social service, access to development and a celebratory social-cultural environment from July-December through multi-cultural festivities. We have found ‘happy’ people in the communities where we work who live in the here and now.
A census survey we did (Bapu Trust, 2011) showed that upto 95% of the community was staying there for 2 years or more. Many families have lived there for generations, along with their extended families. 85% of people stay in their own houses. Migration is not very popular in the community. It is a ‘natural’ community, with young (<20) and old (>40) at 43% and 11% respectively, resembling the population pyramid of a low income country.
Rather than an individualistic culture, we found a ‘group’ culture, with a majority participating in one or other groups: Mitra mandals, self help groups, loan or home business groups, identity groups such as dalits or youth, sporting groups, self development groups, yoga groups, sadhana / bajan groups, groups run by local authorities such as the Urban Community Development Department of Lohiyanagar & Kashewadi areas; etc.
We depth interviewed a woman (Abida Kinkera) who was very active in the loan self help group: For her, such groups served as a social space for meeting and support. It was not just about giving or taking a loan. Altruistic practices of ‘helping others’, even being persuaded to help others, the group recognition of helping and being helped by others, the women ‘paying up’ because of a moral obligation to the ‘givers’, a process of public shaming if not returning the loan; giving a position of mentor to the ‘givers’ and finally, supporting each other emotionally through rough periods, were reported.
We also found several altruistic ‘social workers’, both men and women, whose chosen work was to ‘help others’. A few had political aspirations, but many did not. They helped people negotiate a difficult local bureaucracy by helping in applying, negotiating for schemes and programs, helping in admissions, and accessing a variety of other entitlements. A few women possessed by a jinn or a goddess also served communities by offering oracles or other messages of hope that brought predictability in an uncertain environment, into people’s lives. The ganesh mandals, local cricket club and other ‘minority’ groups also had an active role to play in the social life and support systems in the community. Some older people, also focused on such altruism.
In a separate study (2012-2013, Bapu Trust) we found evidence of significant correlation between the following factors and a mental morbidity rating (Self Reporting Questionnaire of the WHO): (1) number of groups that people participated in (p=0.016) and (2) experience of safety in the community (p=0.048), both aspects being central to the concept of ‘social capital’.
A recent exploratory study on ‘happiness’ (February – June 2014) suggested that despite adversity, some people manage to be ‘happy’. There is an embodied and linguistic experience and expression of happiness (names used for ‘happiness’ in local language). Children, job, family, neighbours, helping others and spiritual pursuits were broadly the themes offered in the context of ‘being happy’. Dropping the past and the future, and living in the now, was also mentioned by some.
In conclusion, the Bapu Trust work in the low income communities of Pune is suggestive of certain cultural and social methods and practices by which people take care of themselves and each other, mitigating the psychosocial consequences of poverty. However, these studies are exploratory and need further research.
Davar, B.V. (2012). ‘Gender and community mental health’. In Community Mental Health in India. Eds. Chavan, B.S, Gupta, N., Arun, P., Sidana, A. and Jadhav, S. New Delhi: Jaypee Brothers Medical Publishers.
McKenzie K, (2008). ‘Urbanisation, social capital and mental health’. Global Social Policy, 8: 359-377
Patel, V. (2007). Mental Health in Low- and Middle-Income Countries. British Medical Bulletin, pp. 1-16.
Prince, M., Patel, V., Saxena, S., Maj, M., Maselko, J., Phillips, M. R. & Rahman, A. (2007). No Health Without Mental Health. The Lancet, 370(9590), 1-19.
Welsh, JA and Berry, BL (2009). ‘Social capital and well being’. Paper presented at the Biennial HILDA Survey Research Conference, 16-17 July, 2009.