Mental health and Development: Modelling community mental health services to influence the national policy environment: Learnings from the project

Learnings from the project

The support grant by NRTT to the Bapu Trust for Research in Mind & Discourse (2010-2013), Pune, was in two parts, one relating to Knowledge Capture [Research] on Mental Health and Development; and the other, relating to researching the effectiveness of psychosocial interventions at the community level. The purpose of the research, executed in 3 different development sites along with control sites in Maharashtra, was to assess the intended and unintended consequences on mental health, in empowerment work, and more broadly, in Development. We examined whether there was considerable difference between main and control sample on measures of mental health.

The second purpose of the project was to “model” and test for effectiveness, a Community Mental Health Program through a 3 year period, including components of: Program Designing, Awareness Building, Training of field workers for primary support and identification and referral;  Counselling and psychosocial interventions; and intervention research. After finishing the bulk of works under this project, we submit a brief report of learnings through this project period.

Mental health project design

The ‘template’ provided by the Government of India for the District Mental Health Program has its limitations. The chief limitation is its medical orientation, without any psychosocial components. This was a concern for us in trying to evolve a new project design for community mental health program. Secondly, DMHPs are considered as feasible only in rural areas. This has divided mental health system between rural and urban areas: Mental hospital for urban area; community outreach for rural area. We believe that community based mental health care is very relevant for urban areas, can include simple yet effective psychosocial interventions, and must be an important policy advocacy domain.

With this background, a large part of our work was studying and tinkering with our project design from time to time, and especially during NRTT review and evaluation process. The Convention on Rights of Persons with Disabilities which was ratified by India in 2007 also gave us new vision for our services, around themes of Community living and Inclusion. We arrived, in this project time, at a basic design of the project as described below:

Program Design: Seher Comprehensive Urban mental health program

The Vision of the program is to create ‘emotionally sustainable communities’. The vision is based on the social entrepreneurial idea that it is possible to transact on positive emotions, especially love, peace, inclusion support and care, in communities.

The strategy to create emotionally sustainable communities is by providing comprehensive mental health services, with all components covered: prevention, promotion and curative services; as well as social services that will help a person to be included in communities.

At core, the program is designed in two tiers, ‘Non-formal care’, and ‘Formal care’.

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 service, peer support and support counselling services, enabling neighbourhood community care system, family counselling, inclusion and stigma reduction.

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 foundation of the program comprises of enhancing sustainability of works through liaison and partnership building, awareness, research, capacity building, advocacy and organizational development.

Mental health systems related learnings

The Project Evaluation conducted in July-September of 2013 by an independent team, assessed the strengths of the different components. Bapu Trust had its own internal research component also, and we obtained results on some components of the project. (1) A good percentage of people in the communitieswere aware of mental health and strategies to deal with it, both medical and non medical. (2) The quality of psychosocial services provided by the Seher program is of high quality. (3) Most clients were satisfied with the services that they had received. (4) The therapeutic groups, having a tight framework as an intervention, had clear positive mental health outcomes irrespective of the methodology used. (5) On the negative side, outreach and rehabilitation of SMD clients, through medical referral to the Municipal Hospital, was of poor quality.

1. Public Health Approach to Urban Community Mental Health

As with all public health issues, addressing mental health, illness and disabilities, also requires a strong community based set up, with tertiary hospitals at the periphery of that system. Selection of slum / development site, with its over 30 or so local variables, may be a significant determinant of outcome of an urban mental health project. Where Development index (civil amenities, socio-economic opportunities, social capital) is low in a slum, that slum may not be suitable for mental health work. More general Development effort may be needed over there. Mental illness is both a health issue and a disability issue, and both aspects must be covered by the project design. If provided for consistently and comprehensively in slum communities, prevalence of mental health problems should go down, and there should be an outcome of secondary prevention of psychosocial disabilities, as in the case of all public health problems. A mental health program must establish the reduction of relapse, the reduction in new cases through prevention activities, and stability of old cases, through a comprehensive design.  Close engagement with communities, knowing their cultural, familial and social economic context, door to door involvement in every aspect of the program, infiltrating existing support systems in the communities with mental health information and skills, helps to build relationship with communities on the topic of emotional health.

2. Goal and purpose of community mental health

The goal of comprehensive urban community mental health should be to ‘create emotionally sustainable communities’. During the project period the purpose of Seher was formulated as, ‘creating sustainable psychological health through community development’.

Over the project period, we discovered that Seher could be built upon principles of ‘social entrepreneurship’ in the field of human emotions and positive interactions. Seher became an ‘entrepreneur of emotions’ in Lohiyanagar and Kashewadi communities. Just like ‘mindful’ use of natural and economic resources is being talked about, Seher talks about the ‘mindful’ use of emotional resources available in the communities. Seher practices this mindfulness, by creating community pathways for multiplying emotional resources and linking emotional development and fulfillment through community development. We have faith that, if money and materials are transactable; if information is transactable; then emotions are also transactable. We take this in a proactive sense of giving, sharing, collection, pooling, recycling, transferring, etc. of positive emotions and capacities of love and care. Positive feelings and emotions are an all important foundation on which ‘social capital’ can be built within communities. Seher has discovered many strategies for doing so. An ‘entrepreneurial’ approach to community mental health work is an important learning of this project.

3. How to do this?

We learnt that, it is feasible and possible to implement our vision, while admitting that there is always scope for further growth and improvement. The project has shown that a spectrum of needs (promotion, prevention and curative; social and rehabilitative) can be addressed if the intervention matrix, as in the case of Community Based Rehabilitation programs, is community based and has a wide set of culturally relevant treatment and healing approaches to offer. (Though we have not developed an intervention matrix with our most successful clinical components, in the next phase, we aim to do this).

The core strategies of the UMH project were developed, over the project period, as follows

(1) Multiplying emotional resources through community networks, formal and non-formal by direct interventions such as ‘Circle of care’, ‘Neighbourhood care’, ‘Capacity building the primary caregiver(s)’, ‘non-formal care’, ‘support counselling’ and ‘peer support’

(2) Provision of specific services to address diverse needs including the classical clinical psychology models, group therapy model, arts based therapies, body based therapies such as nutritional therapies, meditations and visualizations, and a variety of other simple relaxation and emotional holding techniques

(3) Liaison with local government, non-state organized actors, and informal community actors towards inclusion such as local spiritual, recreational, vocational or other activity groups; anganwadi teachers, RCV workers; etc.  These groups have a ‘multiplier’ effect for us, carrying our message of care, offering support where possible and referring people to our services

(4) Distributing cost of care to enable self esteem and self determination of communities, involving local philanthropists, the public health system, UCD department and other local authorities. Comprehensive coverage does not mean ‘very very expensive’. Cost of care should be distributed by leveraging from different private and public agencies, altruism and philanthropy in the slums, and those who give voluntary care.

(5) Preparing the grassroots communities for care through a variety of interactive, visually rich, awareness and skill building activities.

4. Working with people with severe mental disorders

We have had limited success in working with people with severe mental disorders. Barriers have been (1) unavailability of continuing free medical care for such people within public health system in local areas (2) non recognition and poor preparedness for the health problems of this population (3) complications caused by huge burden of chronic physical health problems (3) Lack of faith and skill within Bapu Trust team on use of holistic care and humane crisis care for people with severe mental disorders. We were successful where we provided multiple / different elements of care to 1 client (e.g. Arts Based Therapies (ABT)  group sessions, ABT individual sessions, health and psychiatric care, food, addressing malnutrition, negotiation with family members, help of other service providers for employment, stigma reduction, support counseling, neighbourhood care, building social capital, etc.) We should not wait for months of medication before starting psychosocial interventions for people in extreme states / Severe mental disorders. Those interventions must be a part of holistic care for people in crisis. In some cases where disability / chronicity is high, and whether fully cured or not, we realized that stigma reduction and inclusion should be a separate social goal. Non formal care givers, including volunteers, lay counselors, key resource persons in communities, neighbors, and others can be mobilized for this purpose. We have seen many cases of psychosis brought about by alcohol addictions (alcohol induced psychosis). In such cases, nutritional care, strengthening support system, weaning away from alcohol networks, choosing recreational, sporting or spiritual options, diet support and building social capital helps. Alcoholic men suffer from high level of stigma in the community.

To improve our work with SMD, ideas in the next phase are:

1) To start an Arts based Therapy group for SMD clients with other sources contributions

2) To start community processes of confrontation and negotiation with families where abuse and neglect is high (already started this process minimally and spontaneously)

3) Ensuring continuity of medical care for people with SMD

4) A better tracking system and field monitoring of our work with SMD clients

5. Prevention work

When we entered the communities, we observed and studied many ‘groups’. The primary social unit seemed to be groups (mandals; sporting, spiritual, recreational groups; self help groups; youth, women, other identity groups; etc.) We devised a program on therapeutic groups and also studied the effects of groups. We did not have faith that communities will enjoy groups where no material goods were transacted; and where only emotional issues were transacted. However, after 2 cycles of such groups, we are happy to report that therapeutic groups are welcomed, are popular and effective. Upto 160 people of different ‘vulnerable groups’ have attended our groups (adolescent girls, ‘at risk’ young boys, single women, pregnant women, severely disturbed clients, women affected by domestic violence, care givers of children with mental disabilities). We have a clear and tight structure, as well as process, for running the groups that has been developed and firmed up through the project period. We have psychosocial tools for identifying ‘vulnerability’ in people, so that only those at ‘risk’ having higher emotional overwhelm get recruited. At the time of writing the report, we have developed ‘modules’ that are mixed and matched and applied in different group contexts. We consider this as an important learning in how to conduct structured prevention activities in communities, using simple methods of psychosocial interventions. We developed our own tools or we used existing psychosocial / arts based therapies tools. In this work, we can presently offer – (1) A protocol for running therapeutic groups (2) How to identify people who will benefit most from such groups (pre- and post- test tools) (3) General modules for all groups on Self care, Building social capital, Nutrition for good mental health, Self and Emotions, Communication, Changing thought patterns, Anger management. For each group, certain customized modules are also prepared (e.g. Body module for the Severe Mental Disorders group) (4) Tool for tracking recovery. We do plan to publish our findings as well as Handbook on running therapeutic groups.

6. Mental health as community development

The project has given us huge learnings about handing over ownership of the subject of emotional well being, mental health and disability, to communities, through, networking, promotional activities, referrals, active collaborations with CBOs and local government departments, neighbourhoods, and increasing social capital of our clients through existing groups in the bastis. A wide variety of service providers now work with us providing referrals to us, learning basic ideas in mental health from us, and also rallying to support our clients. Increasing the social capital of people in distress, illness or disability is a mental health strategy in slum communities: Social capital is new concept, but old practice in India: SCARF, Chennai has consistently established the role of social support having better outcomes for schizophrenia. In this way, the cost of our project is defrayed by a variety of other sources contributors (time, spaces in the community, goods in kind, collaboration in action, providing a service, etc.) All key resources in communities and neighbourhood can and should be mobilized and infiltrated with mental health thinking and practice, so cost of care is defrayed in communities, and all peoples take that cost.

Learnings in client work

a. Improving client outcomes

To begin with, BT had a rudimentary Monitoring & Evaluation system for tracking our field work. However, at the time of evaluation, it was pointed out by the review committee that our ‘coverage’ (Number and diversity of clients seen per year) was quite poor. Also, there was ‘information blockage’ at different levels impeding team co ordination and holistic approach. It was also clear that our focus was not too good on client outcomes, due to systemic barriers (e.g. poor quality public health system). We did our own SWOT analysis. By July 2013, towards the end of the project period, we reviewed the monitoring system, and changed it completely. By September, our new system was established, which we now follow. It has improved our client practice, client outreach and support, better engagement of family and communities, improved networking with other service providers, as well as tracking our clients on their recovery. Elements of systemic change included:

1) Making the team accountable for their field time and reporting mechanism and creating a variety of forms for filling at every step of process (1 type of intervention action = 1 type of form to be filled)

2) Single entry psychosocial and other assessment on specific dedicated days of the week (with identifying 20 new clients in each area), 4 days a month in 2 areas

3) Dedicated follow up days for client follow up (with target approach) (Tuesday, Wednesday, Thursday and working Saturdays). Mondays and Fridays for reviews and other activities.

4) Close monitoring of ‘crisis’ or ‘SMD’ clients and better preparedness for multiple actions, often involving the entire team.

5) Case review, team involvement in all clients, and capacity building

6) Compliance and support of timely MIS system

2. Outreach of BT: September 2010 – August 2013

Output of services Output till August 2013 Sept – Dec 2013
1 Number of CMD clients 134 69
2 Number of SMD / MR / other clients 88
3 Number of group counselling clients 148
4 Support counselling clients 370
5 Others 5  
6 No. Corner meetings: 916 2
7 No. of participants in corner meetings 5033 25
8 Awareness Meetings 101 0
9 No. of participants in Awareness meetings 2671 0
10 Poster Exhibition 14 2
11 No. of participants in Poster Exhibitions meetings 990 46
12 No. of Household survey forms filled 616 530
13 Counselling services  
   14 Home visits 5334 2161
15 Social referral clients (linking with other Urban Community Development programs with Municipal Corporation) 415 23
16 Disability Certificate 69 4
17 Total clients with psychological distress or disability 724 69

3. Tools introduced for services

Throughout the project period, we have been involved in creating relevant tools and instruments to catch our project data. A spate of ‘forms’, faithful to the dictum, ‘One form for one action’, were created post Evaluation. A list is provided below.

  Name of form Purpose
 1 Intake form for all clinical clients SMD and CMD clients (covers a range of topics such as medical, social, family history; socio economic features; presenting problem; developmental history; whether mental illness is present in family; chief mental complaints; belief system on recovery).
 2 Assessment form for all group clients For conducting the pre and post test, with 5 point scale, and 6 dimensions – physical, cognitive, emotional, social, behavioural and spiritual.
 3 Mandala assessment Based on Arts Based Therapy principles for groups or for individual counselling clients. Overall assessment of person’s state of being.
 4 Body maps Based on Arts Based Therapy principles for individual counselling sessions or group clients on embodied stress and distress.
 5 Support counselling and follow up form For field workers engaged in support counselling of all psychosocially distressed clients, a brief and functionally orientated form
 6 Corner meetings form Filled by field workers after every corner meeting giving information on subject, number of participants, area, and date / time / venue
 7 Food list Created to understand availability and utilisation of carbohydrates, proteins and fats in the area
 8 Form for social assessment Filled in assessment day to know about support system, family composition, primary care givers, need for livelihood assistance, disability certificate, whether financially independent, etc.
 9 Awareness meeting form Filled by field workers after every meeting, with subject taken, number of participants, discussion points, other than logistics.
 10 Household survey form Filled by field workers for household client identification, Has 12-15 basic questions on psychosocial problems, illness and disabilities
 11 Urban slum selection form Filled by BT visiting team, based on over 30 variables to examine and identify new site for implementing urban community mental health program
12 Session Records Sheet Filled by group facilitator in planning for each and every group counselling session and filed in group file
13 Observation Sheets Filled by Observer to a group, to keep track of changes in each and every participant, filled up and filed in particular group file
14 Other standard tools Brief Psychiatric Rating Scale, Beck’s Inventory, WHO-QOL, Self Reporting Questionnaire, self esteem scale, Roschach, IQ testing, Draw a tree, etc.
 15 Program MIS In Excel sheet format to capture all and sundry program information coming from field
16 Client register To register and track client movement in the center
17 Social referral register To track referrals made to various social, health care and other services, and to know of outcomes
 18 Group registers and files To register all group clients and their attendance in each session; to Register all group sessions and facilitate group co-ordination; group record sheets and observation sheets
19 Daily Monitoring form, Weekly Monitoring Summary, Monthly Monitoring Summary To plan and co ordinate field work on daily basis. Conducted by Dharma and 1 other senior faculty in team every morning and evening, summarized weekly and monthly
 20 Identified client register Information taken from household survey and loaded here for making active referrals and tracking; also records follow up taken with ‘no show’ clients
21 Client registration card To notify each client and place all details, especially follow up in the card
22 Summary MIS Form / monthly MIS records generated and freezed every month

Other than these, audio visuals and photographs are also archived in our system. The forms get checked on regular basis, by different people in the team, as primary data regarding our clients is found in these forms. MIS system provides data, though we are now trying to fill the gaps in the system. Easy retrieval of data is among the major challenges of the present MIS.

Some other learning outcomes

  1.  Service care manual: Created in the early stages of the project, to guide the team what actions to take in the case of which type of client, it needs updation. At the field work level, the manual helps our field workers to apply the same actions, on same ‘type’ of client. It helps to standardize practice at the non formal care level.

2. Group protocol: A protocol for establishing, maintaining and closing therapeutic groups was created, to guide us in the steps involving in running groups.

3. Awareness efforts: A core part of the project was on awareness, and we devised the following types of awareness programs with IEC materials to cater to different information needs of the community (promotion, prevention and cure); and also to enable referral to center.

1)      Corner meetings

2)      Awareness meetings

3)      Poster exhibitions

4)      Positive mental health events with various stakeholders (anganwadi teachers, RCV workers, policemen)

We found that ‘corner meetings’ held nearby households within the gulleys or in people’s homes, made best impact in terms of clinical referrals to the center. Corner meetings also addressed very specific topics of concern to households. The corner meetings were utilised not only to share information, but also to act as a therapeutic space in the immediacy of people’s homes. In case one of our clients is facing stigma, we take out a ‘corner meeting’ in his or her neighbouring area. For establishing a neighbourhood support system also, the corner meetings are very useful.

Awareness meetings with larger gatherings (50+ people to a meeting) addressed common stress related problems of particular groups (e.g. autorickshaw drivers, anganwadi teachers, students, policemen, etc.). Events during special occasions (e.g. ganesh festival) gave the opportunity to rope in local authorities and opinion builders, local influential organizations, into our work.

 4. Research tool on Mental health and Development covering following areas: Socio demographics; autonomy; safety; access to development; health; mental health; addictions; pain; social networking. The research findings have been quite useful, showing new associations between mental health and development, thereby validating the tool.

5. Publications:

In the project time, several papers were presented and published, and continue to be. We were encouraged by the opportunities we are getting to publish about our work and learnings from the program as an innovative ‘case study’. We have had the opportunity to see the project from new perspectives due to these academic pursuits.

1) “Gender and community mental health” in Community Mental Health in India, edited, BS Chavan, Nitin Gupta, Priti Arun, Ajeet Sidana and Sushrut Jadhav, Jaypee Brothers Medical Publishers, New Delhi, 2012. The book is the most comprehensive compilation of community mental health work happening in the country. Davar’s chapter described our UCMH program from a gender point of view.

2) “Urban community mental health: A local, not global, issue”, BV Davar, Paper presented at the “Global Mental Health: A World in Denial” Conference, Royal Society of Medicine, 26th March, 2013, organized by RSM in collaboration with the Royal College of Psychiatrists, London.

3) “Single women and mental health interventions”, Paper being prepared for publication.

4) China Mills (PhD Intern at Bapu, presently, Faculty, Oxford University), and Bhargavi Davar ‘Crossing disability/Crossing borders: a local critique of Global Mental Health”, In, Disability in the Global South: The Critical Handbook, Eds. Shaun Grech (Manchester Metropolitan University) and Karen Soldatic (University of New South Wales) , Springer Verlage, 2014.

5) Bhargavi Davar, “Embodied psychosocial stress among women in low income communities and recovery”, Key note address at INTAR Conference, 2014, University of Liverpool, Liverpool. (Forthcoming)

6) Bhargavi Davar, “Poverty, happiness and well being”. Paper presentation at the ‘ASA14 Decennial: Anthropology and Enlightenment’ Panel P63 (Economic wealth and mental health: questioning the paradoxes). 19-22 June 2014, University of Edinburgh.

  1. Films: Various films were made in the project period, both for creating awareness in the community, including: a. Aadhar (on providing psychosocial support), based on the story of one of BT clients, Bapu Gore

b. A series of 6 short amateur videos with subtitles, on the UCMH project design, with some case studies

c. Footage available for a number of trainings that we conducted for our own staff.

All amateur videos have been uploaded on YouTube.

8. Pune for peace campaign: A road show was created with a drums circle and street play spreading the message of keeping peace in families, to enhance mental health of everyone. A film on this has been uploaded on YouTube

  1. Trainings:

Through the project period, we also created a variety of basic and advanced skill based modules at the level of ‘non formal care’. Trainings included:

  1. Basics of counselling (10 sessions, including ‘mental health’, ‘identifying mental illness’, non judgmental approach, emotional holding, active listening, problem solving, etc.)
  2. Advanced counseling skills such as Narrative therapy, grief therapy, cognitive behavioural techniques, non violent communication, counseling victims of violence.
  3. Empowerment trainings, such as Human rights based approach to services (CRPD), Gender, violence and sexuality
  4. Group facilitation skills
  5. Developing group modules in:

– Self

– Caring for care

– Communication

– Handling emotions

– Nutrition for better mental health

– Creating social capital / circle of care

– Managing hallucinations

– Anger management

  1. Basic arts based and other breath and body based therapies skills for community workers

Exposure to the Project

In the last phase of the project, international and national developments in making of new laws and policies in alignment with the Convention on the Rights of persons with disabilities (CRPD), brought interest and attention to our Community based mental health project. We had the opportunity to exchange project design and details with donors, civil society organizations, academic departments, disability activists, CBOs, DPOs and other stakeholders. Amateur video films were created for this purpose, other than still photographs. Other donors such as Forbes Marshall and Goyal Foundation have also joined in and contributed financial support to aspects of our project. Open Society Foundation New York, supported a ‘Study tour’ of NGOs from 5 other Asian country (Nepal, Philippines, Bangladesh, China, South Africa) to visit our project and share cross learnings from respective country situations. OSF also facilitated travels to neighbouring countries (Nepal, Philippines, Hong Kong) to share news on good practices in the context of the CRPD. Open Society Foundation people were also there to learn, as were some key cross disability leaders from these countries. In the next phase, OSF will support BT to develop an ‘intervention matrix’ that will capture the key psychosocial intervention elements and good practices found in our, and other related, projects in the Asian region. Other than these, we regularly attract international post graduate students and student interns to study our work, conduct research, write academic papers, etc.

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