Seher

A Position Paper

Seher:

Comprehensive Urban Community Mental Health Interventions

 Perspective to urban community mental health

The purpose of Seher[1], is sustainable psychological health through community development [2]. The project is built upon principles of social entrepreneurship, i.e. multiplying emotional resources through community participation, to enable the full inclusion and participation of people with diverse needs. If money and materials are transactable; if information is transactable; we believe 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.

The core strategies of the project are:

–          Multiplying emotional resources through networks, formal and non-formal

–          Partnerships with local government, non state organised actors, and informal community actors (neighbourhoods, groups, etc.) towards inclusion

–          Distributing cost of care to enable self esteem and self determination of communities

–          Provision of specific services to address diverse needs

–          Preparing the grassroots communities for care

We work in two urban slums of Pune city serving a population of 50000 people.

We offer comprehensive health and social care by tying up with the local services (health and social) provided by the state and the district level authorities (Municipality); as well as a variety of non state actors, formal and informal.

Inclusion of persons with psycho-social / intellectual / multiple disabilities, recovery and positive mental health are targeted outcomes of our community development work. The vision of UMH program work is to enable communities to be psychologically contained, all emotional needs met, being inclusive of mental health needs of diversity of people, including those with disabilities [3].

The program effects this objective by sourcing all available resources and multiplying effects through social and service networks: the local authorities (different departments of state and municipality), their services (social, livelihood, health, education, food), existing community networks and support systems and psychological / cultural resources (informal care givers, traditional service providers, families, groups and neighbourhoods).

The project has core belief in distributing cost of care between state and communities, with object to enhance self esteem, self respect and self determination of communities. The project facilitates transformational processes in the community, towards strengthening supports; activating diversity of formal and informal development services for people with disabilities; infiltration of emotional care into existing social networks; enabling a community to march to the final frontier of inclusion and participation of people with multiple, intellectual and psychosocial disabilities within their communities.

Operations

Multiplying emotional resources:

This section describes some key operations of Seher in building inclusive and supportive systems of care (“Circles of care”) in the community by multiplying emotional resources:

–          Neighbourhood care / alert: When a particular person or family runs the high risk of isolation, neglect, health / mental health crisis, starvation; or facing high level of attitudinal or cultural barriers relating to their distinction, exclusion or restriction within the community, due to psychosocial / multiple / intellectual disabilities; we do “corner meetings” in the neighbourhood of that person. A corner meeting happens within the spaces of the kohlis (hutments), sometimes in people’s homes. Following corner meetings, we engage the neighbours in continuing conversations about that particular family, or person, solicit the support of caring neighbours / friends, and their proactive support in crisis situations. In this way, neighbours, particularly women or others who are not out at work for the day, provide support on child care, basic needs, emotional support, help in crisis, etc. We garner community support and neighbourhood care in this way for people having psychosocial issues; in crisis; or people with long term psychosocial / intellectual / multiple disabilities.

–          Physical space for expression: We negotiate with local agencies / philanthropists / municipal offices for space and create safe spaces in the community for self expression. The spaces are used for running support groups, and awareness activities, screening of films, etc. Such spaces are utilised by both persons with psychosocial disability, as well as family members, and other community members who may be experiencing mental stress, disturbance or disability. Larger groups, local residents, and others participate in the activities.

–          Social networking: With respect to excluded, stigmatised or isolated individuals, or those without any social support systems, we link up that individual to local support groups, engage them in our corner meetings, link them up with learning classes, recreational groups, vocational training or other activity groups that they can go to in the locality, based on their interest.

–          Inclusion: While offering a range of mental health services, we do social interventions to address the issues of people with psychosocial disabilities who are excluded, abused or otherwise seriously disempowered. Peace building and reduction of conflict is one of the important strategies we use. We use social negotiation and arbitration methods with family members (e.g. key message of “stop quarrelling, start caring”), put social / pressure, and moral dilemmas before relatives and neighbours (e.g. “This is your community / family / child, and how can you…”), friends and extended family. Where needed, we use the legitimacy of law (e.g. Domestic Violence Act, local police) in preventing atrocities.

–          Mental health for all, including people with psychosocial / intellectual / multiple disabilities: Our program does not target / single out specific individual(s) as having a “special” need. We offer services for all people in the community, and have diversified strategies so that maximum needs can be envisioned and planned for, if not ultimately met. We capacitate the community (anganwadi teachers, RCV workers, school going children, other grassroots groups such as Ganesh Mandals) on various topics such as healthy lifestyles, positive mental health, emotional life, care giving, having peaceful families and neighbourhoods, giving support, relationships, parenting, social equality, chronic illness, pursuit of creative skills, play, social networks, inclusion, addressing stigma, etc. We believe these efforts will impact how the community will receive people with psychosocial disabilities. Some groups with whom we work closely (e.g. support group members, anganwadi teachers, RCV workers) have a multiplier effect for us, carrying our message of care to others, other than our own clients. We have started an initiative called ‘Pune for Peace Caravan’, where messengers of peace travel through the city and do various activities in the city, particularly slum areas, on keeping peace and giving care.

–          Peer support: Field worker highly resourceful in the community offers being a proxy parent / sibling / relative / friend / support person for people with psychosocial difficulties or disturbance. Proxy relationships are widely resourced by grassroots workers (who are a part of the community itself) to share their own emotional resources; and influence their local community members to share likewise with people with lower emotional resources.

–          Home visits and door to door counselling:  Grassroots workers from the community trained by us offer door to door counselling for people with higher level of need. They have a ‘beat’ everyday, visiting people, connecting, supporting and referring.

–          Capacitating key resource persons:  (developing this aspect in the coming year) Some of those who participate in our therapeutic groups (around 60 people at this time) will become key resource persons in the neighbourhood. Their further capacity building will result in their acting as a peer support person in the community;  a caring neighbour; someone who can intervene in case of crisis in the neighbourhood; be vigilant to health and mental health issues in their neighbourhood; be the ‘word of mouth’ channel for accessing services; etc. This will be the most informal system of care in the community, a middle cadre between families / households and grassroots program workers, sustained on community resources alone.

 Partnerships with local government, non state organised actors, and informal community actors (neighbourhoods, groups, etc.) towards inclusion

–          Health care at the doorstep: We have linked people up proactively with a variety of government health services in the locality; and activated the local municipal hospital to provide comprehensive medical and psychiatric care.

–          Enhancing access to social services and empowerment resources: The program serves as a network hub between people and various services (government and non government), enhancing client access to disability certification, education, employment, vocational training for being productive in the open market, food, social and cultural life, justice, financial support, self employment, government schemes and allowances, etc.

–          Capacity building: We are infiltrating a variety of government and non government groups and actors with mental health knowledge and skills (anganwadi teachers;  school teachers; children in schools; college faculty and students; RCV teachers; general public; communities and neighbourhoods in our work areas). While some programs are brief, others are extended, running into at least 6-10 capacity building sessions. We do this through poster exhibitions in the marketplace; screening movies in public areas; group sessions with specific mental health promotion objectives.

Distributing cost of care

–          Physical space for expression: We negotiate with local agencies / philanthropists / municipal offices for space and create safe spaces in the community for self expression. The spaces are used for running support groups, and awareness activities, screening of films, etc. Such spaces are utilised by both persons with psychosocial disability, as well as family members, and other community members who may be experiencing mental stress, disturbance or disability. Larger groups, local residents, and others participate in the activities.

–          Other contributions: A variety of health providers in government and non government provide free or subsidized health care and social support / protection to our clients. Scholarships, loans for business, food / food grain for those in hunger / starvation, pensions, allowances, disability benefits, HIV testing, nutritional support, lab testing, etc.

 Provision of specific psychosocial services to address diverse needs

–          Promotion of mental health: Sustained activities with a variety of groups on promotional aspects (self care; relationships; communications; performance pressures; anger; caring for others)

–          Prevention of psychosocial disabilities: Working with high risk groups on basis of their mental health needs. Therapeutic cycle for each group includes identifying needs; recruiting group members; pre-tool; clinical assessments; setting therapeutic objectives; sessions between 12-14; home visits; closure; and post tool.

–          Invidual counselling – Basic: including giving space for ventilation, active listening, non-judgmental communications, being client centered, exploring preferences and choices, providing emotional holding, validation of emotions, building trust, befriending

–          Advanced counselling / psychotherapeutic techniques: some aspects of cognitive behavioural techniques such as facilitating problem solving, building on strengths, narration and re-storying, working on understanding; making stressors discrete (unbundling stressors) for further process; insight building; building connection for person between [stressor – emotion – action] cycle; working on relationships; unbundling emotions;  thought stopping; moving from negative emotions to positive emotions; behavioural modification; daily scheduling / structuring; games to improve cognitive performance; family counselling.

–          Grief counselling: Space for expressing grief, accepting loss, addressing the issues of bereavement and events and emotions around that, including trauma; addressing loneliness; hopelessness and loss of vision for future.

–          Anger management: Deep breathing and other breath based techniques; ensuring physical safety; counting backwards; ventilation with peer; classic relaxation techniques; drumming.

–          Animal therapy: Connecting clients with local animals (e.g. dogs) to care for

–          Arts based therapy methods: chanting, breath practice/ meditations, visualisations, (agricultural) massage; awakening the senses (touch, smell, taste); encouraging pursuit of creative arts (music); painting and drawing;  stories; theatre work (role plays- “getting into the shoes of…”); moving from expression to emotion words (find words for… ); nurturing communications; techniques for altering mood; rituals (healing light ritual, wellness prayers, prayers for self, affirmations); movement based healing methods (rhythm, free movement); physical activities such as yoga exercises, stretches, etc.

–          Faith: Build on people’s faith and core belief systems; their local ritual practices; enabling choice in spiritual / religious pursuits.

–          Diet and lifestyle: Give information on balanced / mental health friendly diets (protein, oils, good carbs); basic stretches and physical exercises.

Preparing the grassroots for care

One of the key challenges in urban community mental health intervention, is giving flesh and blood to the ‘levels of care’ pyramid. A typical scenario, is while having the mental health professional presiding over all components of services, the levels below are not differentiated with roles, competencies and skills. This makes the communities dependent on experts, a challenge that every community mental health program faces. Such a program is not sustainable, as it is costly, and how much can one mental health professional do, in any case? Further, in such a vertical model, the psychosocial interventionists (clinical psychologists, psychiatric social workers, social workers, field workers) are given only one task of disease identification and referral. The skills that they have received from their disciplines go unutilised, leading to de motivation, frustration and staff attrition.

In an alternative model, energies will be put into capacitating the grassroots with psychosocial skills in emotionally holding and transforming communities; preparing the community for inclusion and participation; and preparedness in times of crisis. In our Urban Mental Health project, there is a flow of knowledge, competencies and skills from grassroots to the expert; equally, the other way around. Mutual listening and learning helps to get a cat’s eye view of ground level realities of living in the bastis.

In practical terms,

–          We created differentiated roles, and responsibilities, moving from mental health expert to formal grassroots (paid by the project) to informal grassroots (volunteers)

–          We created trainings keeping these roles in mind, giving special training for those at higher levels of care

–          We created mentoring / case work / supervision / peer review / reflection / protocol building opportunities regularly for upgrading knowledge, attitudes and skills at each level. (e.g. Almas, a peer supporter, now aspires to be a grassroots counsellor and pursue higher education.)

–          We gave broader profile of work (focus areas) than just case identification, to each grassroots role so that there is enjoyment and structure to the work being done, and skills taught get utilised in the field.

–          We listened when grassroots brought back experiences from the field, worked on it, and tried to match skills received with needs in the community (e.g. how to deal with persons with intellectual disabilities).

Who can do what?

–          Neighbourhood care / alert:  This system is completely held by the fieldworkers and the peer supporters. Only when in crisis, higher level staff is alerted. For example, family affected by suicide, survivors of suicide, domestic violence and trauma, rape or other mishap in the community alerts the field workers and peer supporters, and together, they rally with the neighbours to provide emotional holding and arbitration. Persons with high level of health crisis (starvation), total withdrawal or other critical situations again, while alerting the Project Director, the field workers are able to establish circle of care in the neighbourhood by addressing stereotypes and stigma.

–          Corner meetings: The basic content of ‘corner meetings’ has been developed together with the full team. But field workers and the peer supporters now independently do the corner meetings, which in itself provide human connection at the emotional level, coming together and community bonding, space for expression and identifying needs. For a number of people ‘at risk’, the field workers are able to immediately intervene then and there. For people in crisis, the field workers are able to intervene directly in the neighbourhood, and establish a ‘circle of care’; and bring them to the counselling center / OPD for further interventions.

–          Physical space for expression: We have been able to mobilise local resources for giving us spaces (which amounts to quite a lot, because we run 3 groups at a time, with sessions every week). Field workers are able to mobilise spaces, the group, make home visits in between sessions, provide support counselling for group members, etc. However, only one of the field workers / peer supporters is able to run group independently. At present we are dependent on higher level staff (arts based therapist; clinical psychologist). However, grassroots staff provide assistance during group work; they also learn new skills which they incorporate into their support work.

–          Social networking: Completely held by field workers and peer supporter.

–          Inclusion:  Completely held by field workers and peer supporter. Only when there is a crisis higher level staff intervene (e.g. when there is need for home visit by counsellor to inquire; persuade; put social pressure; arbitrate; or do family counselling). In ‘difficult cases’ we do use the ‘power’ of the organisation as part of social pressure (e.g. peer supporter, while intervening directly during an incident of domestic violence, told the household that she will ‘report to the organisation’! It worked and the violence abated.)

–          Mental health for all: Field workers and peer supporters are able to cover a range of topics mentioned (healthy lifestyles, positive mental health, emotional life, giving support, having peaceful families and neighbourhoods, giving support, relationships, parenting, social equality, chronic illness, pursuit of creative skills, play, social networks, inclusion, addressing stigma, etc.) This is a learning process and topics emerge as per need. They are able to address groups of upto 200-300 people in the community with mental health messages on above topics perhaps at basic level. Arts based therapist, clinical psychologist, along with Project Director, take up advanced topics relating to mental health promotion work in the community.

–          Enhancing access to resources: Completely held by field workers and peer supporters.

–          Capacitating key resource persons:  Field workers and peer supporters will be trained through Training of trainers in order to take on this function.

Non medical approaches at family / individual level:

–          Counselling techniques: Field workers and peer supporters are good at this.

–          Peer support: Completely held by peer supporter.

–          Advanced counselling / psychotherapeutic techniques: Grassroots counsellor (a social worker) can do this. In our project, this work is shared between social worker and clinical psychologist. Basic techniques of CBT / some ABT is being provided by peer supporters and field workers.

–          Grief counselling: Completely held by field workers and peer supporters.

–          Anger management: Completely held by field workers and peer supporters.

–          Arts based therapy methods: Arts based therapist. Fieldworkers and peer supporters can be taught basics. They do take sessions on breath practice; relaxation techniques; chanting; drumming; physical exercises; advice on nutritious food; independently.

–          Faith: Clinical psychologist, arts based therapist.

–          Diet: At all levels.

–          Social networks: Completely held by field workers and peer supporters.

Bhargavi V Davar,

Pune, 2012

For the Bapu Trust.


[1] Urban Mental Health Program, Pune, of the Bapu Trust for Research on Mind & Discourse, Pune

[2] Bhargavi Davar, leader of this project, is an Ashoka Fellow, and believes in psychologically sustainable communities and integrated development work.

[3] While we acknowledge that mental health covers whole populations, psychosocial disability is specific to persons who, other than impairment, face environmental barriers to their full enjoyment of all rights and freedoms on equal basis with others. A strategy that we are working with right now, is not to segregate people with psychosocial disabilities from the communities by creating ‘special’ domains for them, and keeping project boundaries fluid.

Reaching hundreds through Ganesh mandals

Mental health goes public

(c) Bapu Trust for Research on Mind and Discourse, 2012