Community based mental health services for people with mental illness
Item
- Title
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Community based mental health services for
people with mental illness - extracted text
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DRAFT
Community based mental health services for
people with mental illness
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Manual- community mental health and development for the
field staff
BNI Team
Basic Needs India
lasic Needs India
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...promoting mental health
and development
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Contents
Acknowledgment____________
Preface_____________________
Chapter 1
Approach to manual_________
Chapter 2
Introduction to training_______
Chapter 3
Mental health and care services
Chapter 4
Capacity building____________
Chapter 5
Sustainable livelihood________
Chapter 6
Documentation and advocacy
Chapter 7
Project management_________
Chapter 8
Exposure visit_______________
Chapter 9
Field support________________
Chapter 10
Energizers
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CHAPTER I
Manual for the field staff to implement community mental health and
Development programme
Approach to manual
The manual on community mental health for the implementers would help the field staff
to include community mental health programme in their community based rehabilitation
programme. This also helps the field staff in identifying people with mental illness in
their communities and to design community based interventions in meeting the needs of
people with mental illness. The manual would give an out line of each module, each
session, teaching methodology, information/ supporting documents for further reading
will be provided in the manual.
The field staffs undergoing the training should have an experience of working with the
marginalized in the community and have an experience of working with people in the
community. The field staff should have inculcation/ openness to include mental health
issues in their development work. The field staff should also have an experience of
working with the self help groups, formation of federations and experience of advocating
with the authorities.
It is important that we read through the whole manual and understand as much possible
the development approach for meeting the needs of people with mental illness, which is
holistic. The basic emphasis is given to developing right attitude and right approach, so
that people with mental illness are treated rightly and respected in the communities.
Opportunities to reflect on how the ‘development and community based approach’
would help in creating favorable environment for people with mental illness to lead life
with dignity, their rights are respected, and provide opportunities for their recovery and
raising voices so that they can advocate for their rights and entitlements. The process of
reflections is facilitated through raising relevant and significant questions through out
the manual and attempting to brainstorm on the questions, to change our own attitudes
towards people with mental illness.
We believe that following the outline and proposed methodology and sincerely
participating in the group discussions and reflections would help us to acquire
knowledge, skills, attitudes and ability to include people with mental illness in the
development activities of the organizations. The manual also facilitates in improving the
quality of our reflections through emphasizing the ‘perspectives’ we need to gain, where
in the good practices been theorized, so that many can benefit and work towards
changing the world.
Another important aspect of this manual is to develop human force in community mental
health, imbibe skills (consultation, participation, voices guiding the advocacy) in
involving people with mental illness and their families in their own rehabilitation. The
methods that are introduced in the manual such as role plays, small group discussion,
brainstorming, case studies, demonstrations, problem analysis- drawing tree, group
activities are useful in promoting the learning process. This process helps in the
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involvement of the trainees in the programmes, meant for their own development. In
short, these methods are participatory in nature.
Yet another important feature of our manual is continued support even after the class
room training at the field level. The class room training are followed by two days of
exposure visits for the community mental health and development programme (already
implemented programme). The class room training been divided in two phases of 3
days each. During the interim period, the trainees will be supported with field training to
initiate community mental health and development activities. The field support is
designed to provide once in 4 months of 2 days duration at the organizations. Once the
right attitude been formed, trainees (field staff) would tend to seek the information
required work towards improving the quality of life of people with mental illness.
Why this manual?
The lives of people with mental illness is governed with many problems they encounter
from the society like stigma, discrimination, isolation, marginalization, no respect, no
concept of dignity for people with mental illness on one hand and on the other hand
there is limited resources in terms of human resources, lack of understanding from the
available resources and financial resources from the government to meet the needs of
people with mental illness. The issue is compounded for person with mental illness if he
or she is poor with the family and the person getting into the cycle of poverty
exacerbating mental illness and vice versa. The human resources scarcity is governing
the mental health sector, we do need human resources of various levels of categories.
The national organizations continuously been training mental health professionals
(psychiatrist, psychiatrist social worker, clinical psychologist, psychiatric nurse) in the
country. There are various some manuals been developed for different categories of
people like rehab workers, health workers, NGOs etc. This manual is unique as it meet
the training needs of the field workers, draft methodology for the training is also given in
this manual along with the reading materials, simplified for the field staff. After the field
testing for one year same will be translated in the local languages so that it can have
wider coverage. These efforts would go in the way of reaching the most marginalised
sections of the society.
Who should use the manual?
This manual is to be used by the trainer’s team consisting of the field staff/coordinators
having experience of implementing community mental health and development model in
the community. The trainer’s team should have
1. Preferably have some experience in interviewing and working with the families of and
persons with mental illness.
2. Preferably have attended training workshops to learn the required techniques and
skill of community mental health and development model.
3. Known the contents of this manual thoroughly before beginning any intervention.
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Who is the target group for the manual?
This training manual has been designed as a tool for training, keeping in mind field staff
of the organizations. The manual should be able to meet the training needs of the field
staff/coordinators of CBOS and NCOS (field staff would have some experience of
working in the community with the educational background of plus or minus 10th
standard). The definition of the field staff include, any person involved in community
development activities from the organizations/people’s group who is passionate to work
with the marginalized people in the community.
Where it has to be used?
Basic Needs India believes that mental health is a development issue, hence can be
included in all the development activities of the development organizations working in
the community.
What are the objectives of the manual?
The overall objectives of the manual for the field staff is:
1. To build capacity of the community based organization/NGOS for implementing
community mental health and development programme.
2. To build skills of the field staff in identifying people with mental illness and their
needs in their community.
3. To develop skills in organizing community based interventions involving
community in meeting the needs of people with mental illness in their community.
4. To build/capacitate the existing people’s organizations to advocate with the
government for meeting the needs of people with mental illness.
5. To understand mental health is a development issue, in can be included in any
development activities.
What are our basic beliefs?
Basic Needs India believes that:
1. Mental health is a development issue, can be included in all the development
activities of the organizations.
2. How ever poor or ill the person is, has the capacity to manage his or her life if
provided with support.
3. People with mental illness should be encouraged to voices their needs and work
towards fulfillment.
4. Consulting people with mental illness, their own life experiences are valuable and
meaningful to be understood.
5. Development approach is people gaining increased control over their lives and
making optimum utilization of their potentials
6. Individual and group reflections would help to internalize learning’s and changing
the attitudes.
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What extent the manual be?
The trainers (trainers group identified) should be able to train the field staff of the
CBOs/NGos using the proposed manual. The manual should aim at support the
trainees in designing the community mental health programme, same to be included in
their development activity of the organization.
How many days the training be organized?
I am proposing 6 days of training (as said in the training proposal) with two intervals,
followed by 2 days of field exposure to community mental health and development
activities and 6 days of field support, field support is towards supporting the field staff in
the community mental health activities (like supporting field staff in meeting the needs of
the difficult families, in developing script for street theaters, in designing awareness
programmes to community groups like women’s group, youth groups, ICDS teachers
etc).
What is the structure of the manual?
The structure of the manual should be; providing session plan for six days along with
the trainers notes for summary for each session; reference materials for reading should
be part of the manual; guidelines for the trainers to use the manual; designing field
support (as proposed in the CBR proposal) etc. The community mental health and
development manual would have 5 modules (as proposed in later pages).
The Manual will :
• Give an outline of each session with proposed topics, teaching methodology and
the time devoted.
•
Provide the relevant support materials to supplement and complement the
training efforts.
•
Lend itself to be used in parts or whole, depending on the needs of the trainer or
the participants.
What is their in community mental health and development manual?
The Basic Needs India Model of Community Mental Health and Development is one
such intervention been evolved through consultation and been tested and proven
effective in meeting the needs of people with mental illness and their families and in
involving them in their own rehabilitation and development. The model of CMHD
incorporates five modules of
1) Community Mental Health,
2) Sustainable livelihood
3) Capacity Building
4) Action Research
5) Management
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These modules work together in the field and have resulted in a holistic development of
the program. This training manual is an effort to consolidate the 8 years experiences of
the implementing community mental health and development programme. BNI has
captured their experiences of working with partners in capacitating the partner
organizations and the field staff for including people with mental illness in their
development work, same been captured in the manual so that.
What are the chapters included in this manual and topics under each module?
1.
2.
3.
4.
5.
Mental health and care services
Capacity building
Livelihoods and Income enhancement
Documentation and advocacy
Community based mental health services Project design
The proposed topics/contents to be included in the manual are given below under the
modules (proposed) for the training programme:
Mental health and care services
The trainees should be able to:
1. Differentiate stress, mental illness and mental retardation
2. Identify people with mental illness among disabled and in the community.
3. Differentiate people with severe and common mental disorders
4. Able to identify and organize care/treatment services locally
Topics to be covered
a. Mental health and mental illness
b. Understanding human behaviour
c. Types of mental illness
d. Organizing treatment services
e. Multi dimensional approach
f. Mental Health in India an over view
g. Stresses in the day to day practice
h. Why community metal health
i. CBR ad community mental health and development prorgamme
Livelihoods and Income enhancement
i
The trainees should be able to:
1. Understand relationship between mental illness and poverty
2. Understand family as a unit
3. Understand about the trade analysis
4. Understand various livelihood options
Topics to be covered
a. Dignity, recovery, prosperity, and self worth
b. Poverty and mental health
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c. Sustainable Livelihoods
d. Trade analysis
e. Livelihood options
Capacity Building
The trainees should be able to:
1. Understand what is capacity building
2. Understand barriers in the familyP and community for the recovery of person with
mental illness.
3. Understanding of consultation would consult people with mental illness and their
caregivers in understanding their needs.
4. Understand needs of the families with mental illness and to design appropriate
awareness programme to deal with the barriers in the family and community.
5. Understand the need for inclusion of people with mental illness in the group.
6. Understand various awareness strategies for various community groups.
Topics to be covered
a. Capacity building
b. Animation
c. Consultation
d. Understanding barriers - Family and community
/y e. Organizing people with mental illness and
groups/associations
f. Awareness generation
g. Gender
h. Mental health and development
caregivers
in
to
self help
Documentation and advocacy
Trainees should be able to:
1. Develop format (individual file) for documenting
2. Develop an understanding on the various legislations related to mentally ill
people in India
3. Have an understanding on the various provisions available for people with mental
illness
4. Have an understanding on the national mental health and district mental health
programmes
Topics to be covered
a. Need for documentation
b. Individual file format
c. Provisions available for people with mental illness
d. District mental health programme and National mental health programme
e. Mental health act
f. People’s with Disability Act
g. UNCRPD and other UN conventions
, h. Human rights
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Project Design
Trainees would have an understanding on:
1. Mental health as a development issue
2. Mental Health in India an over view
3. Need for community based intervention versus institution based intervention
4. Similarities and differences of CBR and CMHD
5. Mental health and development model (BN Model)
6. and ability to design a community based mental health programme
Topics to be covered
a. Strengths of development approach
b. Documentation in the community mental health and development programme
c. Consultation
d. Individual rehabilitation plan
e. Alliance building
f. Review and evaluation
Proposed topics for refresher training:
• Vibrant economy
• Meeting the needs of the Care givers
• People’s organizations
• People’s participation
• Community mobilizing
• Gender analysis
• Prevention and promotion strategies
• Recovery
• Advocacy
• Child mental health issues
• Problem solving approach
• Helping skills
• Communication training
Notes for the trainer
Basic Needs India believes that mental health is a development issue, believes in
people developing abilities to have control over their life situations. This is achieved
through a process which is people centered, people’s participation, process of
consultation and participation oriented, ultimately aiming at people exercising their own
rights and their needs are respected in the community. It is necessary that the trainer
should transfer the true spirit and philosophy behind the Community Mental Health and
Development Model. To facilitate this process it is essential for the trainer to reflect on
the following attitudes and beliefs which drive the CMHD model and our efforts to
mainstream it.
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•
Change is the ‘central’ for any training. Change is continuous, people exposed
with information and knowledge would lead to attitude change. Change is
essential in the individual and for the community.
•
Every human being is a thinking creative person with capacity for action. Every
individual (how ever poor or ill) has the ability to manage his or her life. Trust in
people’s potential and confidence in people’s ability to think, to solve, to express
etc. This is crucial for the success of any development initiative.
•
Critical and creative thinking is the main ingredient for social change. This need
to be nurtured and fostered by the trainer. The trainer needs to question the
prejudices and beliefs of the participants. Help them to acquire new
understanding on the issues.
•
Reflection is crucial for change. Reflection leads to action, and action would
change the situation. By facilitating reflection in the group, this provokes thinking,
leading to change in attitude and in their action. It is essential for the participants
of the training program to imbibe skill of reflection on every day’s inputs and plan
an action based on their learning’s.
•
The group constantly changes; it becomes more and more capable of observing
the content and transforms their learning in their daily life.
•
Learning means change in the thinking, attitude and behavior and not just
acquisition of knowledge. It is of importance that the participants to learn wider
perspective about issues.
•
Every individual or group if given opportunities and exposed to new learning’s
would change for the better.
•
Development is people gaining increasing control over their lives; development is
people making maximum use of their potentials.
•
Reflections would build the capacity of the individuals leading change in ones
thinking
BNI hope that the trainer shall uphold these values and beliefs and reflect them in the
training.
Manual and Session Plans: The manual consists of eight chapters (encompassing
how the community mental health and development model can be implemented), with
the detailed session plans for each module. The session plans include:
o
o
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What the trainer would learn under each module
The number of sessions per module, with the time frame given for each
session.
The methodology planned for each session along with the necessary
handouts/reading materials.
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It is to be noted that the time indicated in the out line need not be binding on the trainer.
Also the user is free to structure the session differently, including variance in
methodology.
Role of trainer:
The manual envisages a training process that focuses on learning rather than
teaching/delivering. The effective trainer is one who is:
1.
2.
3.
4.
5.
6.
7.
Developing self awareness- discovery of self
Understanding the learner
Knowing more and more about people’s learning styles
Understanding the learning process
Selects options for training from existing educational norms
A leader and democratic decision maker
Flexible in designing the training, plan to implement what been designed,
decides not to implement what been planed.
8. Not a strainer rather shapes the learner.
9. Willingness to learn from others.
10. Readiness to respond to the learner’s needs.
11. Trainer grows during the process of facilitating groups.
12. Training is for mutual resource enhancement.
Time Management:
The trainer should have good time management skills. This calls for a good preparation
for the training session. The trainer avoids extending the session timings in general.
Being alert, creative and making spot decisions helps the learning process.
Need to be good facilitator:
Small group work, role play, demonstration, paper readings etc., have been used
extensively in the manual as teaching methodologies. Effectiveness of such strategies
depends largely on trainers’ competence in facilitating the given tasks, and monitoring
and summarizing the sessions. The trainer should encourage the learner to summaries
the sessions rather than he himself consolidating.
Need to use icebreakers/energizers to break the monotony:
There is a list of icebreakers/energizers given at the end of the manual for strengthening
the training process. It depends on the skill of the trainer to use these effectively and
competently to sustain the interest and the energy levels of the participants.
Need for home work/assignment:
Trainer assigns home work to the groups so that they would reflect, discuss in the
group, make presentation on the next day. This increases the motivation for the
participants and also would be able to consolidate their learning’s.
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Reflection dairy:
Trainer introduces the concept of reflection dairy. A 100 pages book will be kept at the
training programme hall. Five trainees would volunteer each day to write the reflection
dairy. The five trainees would discuss among themselves after the end of the training
session, training document the reflection for the day
Exposure visit:
As part of the training, two days of exposure visit will be organized for the trainees to
observe community mental health and development activities in the already
implemented programme (Basic Needs India Partner). The trainees will be exposed to
various dimensions of community mental health and development programme during
these two days. A link between the class room teaching and observing the activities will
be shown to participants. (Detail of exposure visit given in chapter 6)
Field support:
The training continues even after the class room training, the training team would visit
the field to support and mentor field workers in the field. They would demonstrate the
community mental health and development activities to the field workers, support field
staff to deal with the problems at the field level. (Detail of field support given in chapter
7)
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Chapter 2
Introduction to the training programme
Session I
Welcome & Introduction: 20 minutes
•
•
•
Trainer after a welcome expression, invites participants to introduce themselves
along with the food they like most.
On completion, the trainer asks participants to reflect on when asked them to
introduce they said about the organization, place, and the name, does it
describes who the person is?.
Trainer invites participants to express their thoughts on the same.
Expectations sharing : 20 minutes
•
•
•
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The trainer begins the session by asking the participants to express their
expectations
Trainer writes down the expectations on the board.
Trainer presents the objectives of the training program and asks for responses
from the participants.
Trainer shares the training design along with the modules of training (given in
chapter 1, modules of community mental health and development).
Norm Setting : 10 min
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Trainer suggests to the participants set the norms/ground rules for effective
functioning as a group. Norms can be on the lines of:
> Mobile phones not to be entertained, to be kept in silent mode.
> Listening to each other.
> Everyone’s contribution is important.
> Participants speak one at a time and no cross talk.
Familiarizing with the program : 25 minutes
a.) Reflection Daily Dairy:
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The trainer introduces the idea of participants maintaining a reflection Diary,
following certain guidelines.
> Purpose of reflection diary :
o To think further about some aspects of each day’s experiences and
learning.
o To provide an opportunity for issues and concerns within the groups to
be raised.
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o
o
To provide a continuing commentary by participants on the life of the
group.
To bring the group members to a shared starting point each morning.
> Guidelines for the diary :
o Write as an informal diary, not as a report or minutes.
o Keep the emphasis on the life of the group, on the members of the group
and on the process of learning.
o Avoid recording and repeating the factual content or subject matter of
sessions.
o Choose only a few points, events or moments to mention something which
strike you, which seem important or you feel strongly about.
o Write from your own personal observations and experience of the group
and the day.
o Remember that the purpose is reflection and not evaluating.
o Use your own style of writing and ways of expression.
o Write three or four sides only.
b.) Hand Outs:
•
•
The trainer informs the participants that the sessions will be supported by
handouts wherever required.
Trainer asks the participants to read the handouts during the night and get back
to the trainer for more clarification and understanding
c.) Overnight Assignments:
•
The trainer tells the participants that there will be over night assignments relating
to topics including discussions of paper readings ( individually or in groups), and
also other activities, (like Me and My work, Personal Profile sheet detailed in the
last chapter on Strengthening the Trainer).
d) Field support:
The training inputs continue even after the class room input, the trainers’ visits field
mentor and support the field staff at their work place. They would demonstrate
community mental health and development activities and support the field staff in
dealing with difficult families.
e) Exposure visit:
Two days of exposure visit will be organized as part of the training. The trainees
are exposed to community mental health and development activities and the
dimensions from the already implemented organizations.
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Chapter 3
Community mental health
The trainees should be able to:
1. Differentiate stress, mental illness and mental retardation
2. Identify people with mental illness among disabled and in the community.
3. Differentiate people with severe and common mental disorders
4. Able to identify and organize care/treatment services locally
Number of session 11
Session 1: Stresses in the day to day practices
Session 2: Mental health and mental illness
Session 3: Understanding human behaviour
Session 4: Types o mental illness
Session 5: Mental illness and mental retardation
Session 6: Mental health interventions, NMHP and DMHP and multidimensional
approach
Session 7: Prevention and promotional strategies
Session 8: Child and Adolescent mental health
Session 9: Mental health and development model
Session 10: CBR and people with mental illness
Session 11: Why community mental health
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Session 1:
Stresses in the day to day practice : 45 minutes
a. Trainer divides the participants in to three groups
b. Trainer ask each groups to discuss on the painful event/ losses/ difficulties in
their life over last six months
c. After listing down the events, Trainer ask them to describe about their behaviour/
emotions/ reactions to the event
d. Trainer invites the participants to present on the discussion
e. Trainer writes in the black board the reactions of people facing difficult situation,
group them in to physical and psychological reactions
Trainer summarizes the session, describing stress and its reactions
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Session 1
Stress and mental health
Some observations
•
Stress is reaction to an external situation that results in deviation from normal
standards, it is bi product of pressure (physical, psychological and behavioural
pressures).
•
A stressful circumstances is one with which a person can not cope successfully,
or believe he/she can not cope successfully, and which results in unwanted
physical, mental and emotional reactions.
•
75% of the bodily disease is said to be stress related - heart disease, diabetes
and hypertension.
•
Stress can be both positive and negative stress. It is good to have some level of
stress during exams (positive stress), as it helps us to prepare better for the
exams, but if we are extremely stressful (negative stress), it may lead to
decreased performance because of extreme anxiety.
•
Handling stress will increases self image, confidence of the people and gives
innovative ideas/alternatives and creative solutions.
•
Our ability to cope, adapt and accept challenges/changes will help us come to
terms with problems, and boast our confidence level and self image.
Stress is expressed through following expression (voices):
•
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•
•
•
•
•
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Where will it end
Nothing seems to work
Who is responsible for this situation
How much more can I take
Can/will any one help me
I feel helpless to stop this
No one seems to care
What have I done to deserve this
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Definitions of stress:
•
Stress is the internal state which can be caused by physical demand on the body
(disease condition, exercise, extremes of temperature) or by environmental and
social situations which are evaluated as potentially harmful, uncontrollable or
exceeding our resource for coping.
•
Stress is uncomfortable gap between how we would like our life to be and how it
actually is. If this gap is persistent - despite our efforts to reduce it, than we are
distress
•
Stress is state of physiological imbalance in the body which has unpleasant
emotional and cognitive components. Stressor is something that threatens your
safety or well being.
Some common stressful situations:
•
•
•
•
•
•
•
•
Change of residence/migration
Change of teacher
Change of schools
Changing views of people about
you
Child rearing
Death of a parent or sibling and
near one
Disability of some kind
Failure in exams
•
•
•
•
•
•
•
•
III Health
Injury
Loss of a possession
Marriage
New boss in the work
place/leadership
Occupational stress
Onset of menarche
Rapid changes in physical
characteristics/ adolescence etc.
The stress is manifested in various forms like
In the Mind
• Anxiety-getting
fearful or angry
easily
• Mood changes
• Poor concentration
and attention
• Memory loss
• Difficulty in
abstracting
In the Body
• Tiredness
• Headache
• Tense muscle
• Poor appetite
• Feeling of pain
• Disturbed
menstruation
In the Behaviour
• Reduced sleep
• Restlessness
• Increase in
substance use
• Difficult to
complete the task
• Lack of self control
• Over reacting to
the situation
• Mistrust
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Categories of stress:
• Anticipatory stress: always anticipating that any change in their life situation
would lead to stress eg change in the school, new boss in the office etc.
Situational stress: worried about facing the situation as they do not feel
comfortable eg marriage,
•
Chronic stress: exposed to difficult situation for longer duration of time, eg
unhappy married life.
Some ways to manage stress
•
•
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•
•
•
•
•
•
•
•
•
•
•
Adequate sleep and food intake
Become aware of stress inducing
occurrences by writing/understanding
down events that are stressful
Become aware of emotional, physical
and behavioural reactions to stress
Being positive - I can face challenges,
say to your self that I would try my
best.
Creative visualization: visualizing
positive things/achievements
Develop cooperation with others, not
competition, develop some mutual
supportive relationship
Distance/away from problem/stressful
event for a short time
Divert your mind with some
pleasurable events
Do some things just for yourself and to
enjoy like listen to music & watch TV
Elicit family and community support
Physical exercise- Hand gripper,
tennis ball
Follow good and healthy diet
Have a good laugh every day
Learn to delegate responsibilities
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Listen to what others are telling you:
people give their feed back saying you
are appearing tensed, restless, take it
serious
Notice what your medical check ups
reveal
Ona daily basis keep track of how often
you are irritable, fatigued, restless, have
a pain, sweaty palms, raising heart
beats, eating out of control, have
headaches
Plan recreation time and maintain
routines
Pursue realistic goals rather than being
in fantasy and pursuing unrealistic goals
Relaxation and sit still for few minutes
Share how you are feeling with some
one you can trust
Stop smoking and taking substances.
Take at least few sips of water slowly divert mind
Time management.
Try not to be perfectionist in every thing.
Try not to be very critical to others and
yourself
Try not to self medicate
Use anger with physical activity
Mind and Body: relationship between emotions and the physical illness and
disabilities:
Mental functioning and bodily functioning are intimately related. Each influences the
other in health and illness. When we are mentally upset, we experience a number of
uncomfortable bodily sensations. When our body systems do not function properly, we
are not mentally relaxed. For eg. When we are witnessing a child who is coming under
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the wheels of an lorry (unable to save), for a moment, we experience, dryness of mouth,
unable to shout, palpitation, tremors, sweating etc. Similarly when the person with
disability or the family member finds difficult to accept the medical illness resulting
disability, in such situation if we teach them how to use aids and appliance, how for the
interventions will be successful?. Let us examine the various types of associations
between emotional processes and bodily illnesses.
Emotional factors can play a causal role in bodily illness: there are several
disorders, especially those termed psychosomatic disorders, where psychological
factors like mental tensions and worries play an important role in the development of
bodily illnesses. Some of these conditions include peptic ulcer, hypertension, diabetes
mellitus, rheumatoid arthritis. Studies have shown that individuals suffering from
depression are prone to develop many types of physical illnesses.
Emotional problems can present with bodily complaints: several mental disorders,
especially the common mental illnesses, manifest with a variety of bodily complaints. A
person with anxiety experiences several uncomfortable bodily symptoms which include
palpitation, sweating, tremors, dryness of mouth etc. Similarly, depressed patients often
report aches and pains in various body parts, tiredness, weight loss, constipation and
sexual dysfunction. Many people with common mental disorders have an excessive
preoccupation with the functioning of their body parts.
Emotional symptoms can be part of a bodily illness: physical illnesses may present
with mental symptoms as well. For example, a person with anaemia frequently
complains of anxiety, tiredness, lack of energy and disturbed sleep. Hypothyroidism
often manifests with memory disturbances, depression, lack of concentration and
tiredness. Symptoms of anxiety and depression are reported by people with heart
disease and kidney dysfunction.
Emotional problems can occur as a reaction to bodily illness: Physical illnesses
frequently result in emotional disturbances. There are several undesirable emotional
consequences that result from life threatening or chronic physical illnesses. These
include, the physical disability produced by the illness, financial difficulties, occupational
difficulties, difficulties in family life and sexual difficulties. As a result, people experience
varying degrees of anxiety and depression. Fear of death may accompany illnesses like
renal problems, heart problems, cancer etc. leading to emotional disturbances.
22
Session 2
Mental health and mental illness: 15 Minutes
1. The trainer will write in the black board mental illness
2. Trainer will ask the participants to share the words/thoughts that come
to them on mental illness
3. Trainer will list down all the words in the black board
4. Trainer will ask one participants to summarize the words
30 minutes
1. Trainer describes the situation (one early morning, person need to travel a long
distance, he will be in bus stand 1 hour before the schedule time, to get a seat in
un reserved bus. He succeed in getting a seat, while he was sitting, he finds a
person with physical impairment, finding difficult to stand as he do not have seat)
and ask the participants to share their views.
2. Trainer ask the participants to share what they would do in that situation and why
they do
3. Trainer describes another situation, (in the same bus, they find a person, un
hygienic, smelling as he has not taken bath, nor brushed his teeth, found
muttering him self) and ask participants to share their view
4. Trainer ask the participants to share what they would do in that situation and why
they do
5. Trainer asks participants to share why they react differently in two situation
6. Trainer summaries on the attitude of general community on mental illness.
7. Trainer links the earlier presentation.
8. Trainer helps the participants to understand stress and mental illness.
45 minutes
a. Trainer invites three volunteers to be a drivers of the three buses, (1st bus is
agree bus, 2nd bus is disagree bus, 3rd bus is not decided)
b. Trainer gives instructions to the participants that when the trainer finishes reading
the statement, participants should occupy the three buses based on their views
on the statement (agree/disagree/ not decided buses).
c. Trainer reads out the list of some of the prevailing attitudes/misconceptions in the
community.
d. Participants will be occupying the buses,
e. After each statement, trainer asks them to state reason why they got in to the
bus.
f. Trainer shares his views on each misconception and discuss on how to deal with
such situations in the community.
23
Session 2
Health and Mental Health
Health is wealth; all of us want to be healthy. However mere absence of illness is not health. A
healthy person has a sound body; are-happy and contented and ability to face difficulties, losses
and frustrations. They are capable of living in harmony with others, and also to keep others
happy. They see that others are not put into trouble because of them and obtain certain moral
and spiritual values. Such persons who are physically, mentally, socially and spiritually well can
be considered to be healthy.
People become physically ill due to many reasons. Under nourishment, diseases, fluctuations in
the environment, wear and tear of bodily organs, injury to the body, defective blood supply to
specific organs of the body etc., can lead to illness. When an individual is ill, it is usual to
consult the doctor and take treatment.
Like the body, the "mind' too can become ill, and the mentally ill person's sense of well being
and emotional equilibrium are disturbed. The various mental functions like thinking, emotions,
memory, intelligence, decision-making etc., can become disturbed as a result, the ability to work
satisfactorily is also impaired.
It is easy to imagine and share the experiences and difficulties caused by damage or
dysfunction to any part of the body. For eg., all of us know what it is to have high fever,
blindness or a broken leg. So we usually react and sympathize with a person who is physically
ill or disabled. However, most of us do not understand what it is to be mentally ill. We often fail
to sympathize with a mentally ill person. When a person becomes mentally ill, not taken to a
hospital immediately for proper treatment, rather go to faith healer, temples and black magician
for cure. To add to the problem, currently most of the mental health care' facilities are available
only in cities and towns and not reaching the masses, who are in the villages.
A mentally healthy person as capacity/skills to:
>
>
>
>
>
>
>
>
>
Respond positively to the crisis situations/problems
Coping skills and mechanism to handle problems
Positive attitudes
Balancing the life situations
Good stress management
Assertive behavior
Identification of ones own strengths and weaknesses
Clear perception of reality
Mastery over the environment
24
Session 2 b
Myths about Mental Illness
Children do not get Mental Illness
People do not recover from Mental Illness
All Mentally ill people are violent and dangerous
Marriage “cures “Mental Illness
Evil spirits cause Mental Illness
Past misdeeds cause Mental Illness
Mental Illness spreads through constant contact
Rituals can cure the mentally ill
There is no cure for the mentally ill
The mentally ill have to be kept isolated.
25
Session 3
Understanding human behaviour: 30 minutes
1. Trainer divides the three groups
2. Trainer distribute the flip chart to each group
3. Trainer shows the flip chart and ask the participants to create story and to record
their observation on the flip charts
4. Trainer invites group to make presentation of the group discussion
5. Trainer gives his observation on the flip chart
6. Trainer summarizes the discussion saying that behaviors of the people with
mental illness have reason.
7. Trainer asks the group to brainstorm on the reasons for violent/odd behaviours
of people with mental illness
8. Trainer list down the responses in the black board
9. Trainer asks group to reflect in difference in perception of families/communities
on mental illness and other illnesses.
10. Trainer asks group to reflect on when self worth get affected, how the people
with mental illness would feel.
11. Trainer summarizes with the presentation on why do mentally ill people become
aggressive and be aware of signs of violent/aggressive state of mind.
30 minutes
a. Trainer each invites participants to say about one symptom/observation of
mentally ill person whom they have come across.
b. Trainer writes down all the words/responses of the participants in the black
board.
c. Trainer asks the participants, do we all experience above listed symptoms in our
day to day life.
d. Trainer also ask participants, that often in our day to day conversation we say
that “ I am getting mad” “my mind is stuck”, “if you irritate me I will become mad”,
I need to smoke/ drink coffee to make my mind work” are we certifying that we
all are mentally ill.
e. Trainer summarizes the discussion with presentation on characteristics and
features of mental illness
60 minutes
1. Trainer makes brief presentation on the Structural Model of mental health, causes
of mental illness
2. Trainer divides participants in to five groups
3. Trainer gives the case vignettes to group for smaller group discussion
4. Trainer asks the participants to identify mental illness in the given case vignettes,
identify possible causes for mental illness and to substantiate their answer
5. Trainer invites the participants to share the discussion
6. Trainer shares his views and re assure on the characteristics, causes and on the
structural model of mental health.
26
BEHAVING IN A STRANGE MANNER
Session 3
Mental disorders and its manifestations
Mental illness is a group of disorders characterized by significant disturbance in thinking,
emotions and perception resulting in psychological and/ or behavioral symptoms lasting for
significant period of time. Mental illness is a general term, referring to a group of illnesses in the
same way that heart disease refers to group of illnesses affecting the heart. It could be a severe
disabling condition like schizophrenia or less severe condition like adjustment disorder. It
includes conditions attributed to organic causes or to those caused by stress. It includes brief
episodic illnesses to long-term persistent illnesses. It varies in its presentation, course and
outcome. For some people it will come and persist throughout their lives. Some people
experience their illness only once and fully recover and for some it recurs throughout lives.
o
Certain symptoms are specific to a particular mental illness (delusions, hallucinations,
obsessions); however many illnesses herald their onset with non-specific symptoms (social
withdrawal, anxiety). Sometimes, the typical symptoms appear late in the course of the illness
after a prolonged period of non-specific symptoms. Waiting for occurrence of typical symptoms
would delay early intervention and therefore affect the prognosis. However definite diagnosis of
a particular illness is considered only when a certain numbers of symptoms are found for a
certain period of time.
Three characteristics of mental disorders are:
•
•
•
Changes in ones thinking, feeling, memory, perceptions and judgment resulting in
changes in talk and behavior which appear to be deviant from precious personality or
from the norms of community, last for long period
Changes in behavior cause distress and suffering to the individual or others or both
Changes and the consequent distress cause disturbance in day to day activities, work
and relationship with important others (social and vocational dysfunction)
Features of mental illness:
Common features in all mental illnesses are its basic abnormalities in thinking, emotion and
perception, however the degree and extent of the abnormalities may vary. For example a
person with Schizophrenia may have predominant disturbance in thinking process and a person
with mood disorder may have significant disturbance in emotions. The manifestation of these
abnormalities can be easily recognized from the appearance and behavior. Any behavior out of
the ordinary or the limits of 'normal' acceptable cultural and social norms may provide the first
clue. Changes in behavior if persists for longer than expected, often make one to suspect
mental illness. Disturbances in the occupational and / or social functioning might also point to
mental illness.
Identifying mental illness as early as possible would help in early recovery and in the overall
treatment and prognosis of illness. Family members, neighbors and friends of a person often
are best source of information and it is always good to respect their opinion and also to talk to
affected person before initiating appropriate intervention strategies. Most mental illnesses can
be effectively treated, advances in drug management, psychosocial interventions and
rehabilitation services have made outcome of mental illnesses as good/better than those of
physical illnesses.
27
Features (symptoms) of mental illnesses are broadly grouped as:
• Disturbances in bodily functions
• Changes in mental functions
• Changes in personal and social activities
Disturbances in bodily function:
a) Sleep: Person finds it difficult to fall asleep. He stays awake and worries about his inability to
sleep. At times he may wake up in the middle of the night, and finds it difficult to fall asleep
again. He may have disturbed sleep through out the night or may not sleep at all. He does not
feel fresh in the morning. Any of these types of sleep disturbance can be a manifestation of
mental illness.
b) Appetite and food intake: Person does not have proper appetite and eats less. At times
although appetite is normal, the individual does not enjoy what he eats. Patient may have
increase in appetite and eats more. He may lose weight or gain weight.
c) Bowel and bladder functions: Person may pass urine more frequently than usual. He/she may
have loose motions or become constipated. Some patients may soil their clothes and remain
unaware of it.
d) Sexual desire and activity: Patients may lose interest in sex. Men may also complain of
difficulty in sexual performance or inability to enjoy sex.
e) Bodily complaints continuous physical disorders/pains, without having evidence of physical
illness. For e.g. person complaining of headache or body aches, same cannot be explained on
the basis of known physical illness or though investigations.
2. Changes in mental functions:
a) Behavior: person may behave peculiarly and in a strange manner. His behavior may irritate
family members and other people or place them in awkward and embarrassing situations.
Person's behavior can be dangerous to self and others. He/She may become overactive,
restless and wandering aimlessly. He/She may abuse and beat others for trivial or no reason.
On the other hand, the individual can become very dull, inactive and lose interest in the day-today activities. He/she may sit or lie down for hours or at times, days together, refusing to move
even to attend to their bodily needs
b) Talk (thought process): Person may talk excessively and unnecessarily or may utter only a
few words and remain silent. At times talk becomes irrelevant and incoherent. The individual
may express certain peculiar and wrong beliefs which are not shared by others. For example,
the he/she may say that somebody is spraying poisonous gas into eyes, that thousands of
worms are crawling under his/her skin or that his/her food article is mixed with poison.
c) Emotions (feelings): The person may exhibit excessive emotions of sadness or happiness.
Emotions inappropriate to the situations may be shown. In contrast, some may be unable to
express any emotions at all and just sit like a statue. Others may laugh or weep.
d) Perception (sensations): Person's ability to understand various stimuli reaching through
different senses can be disturbed. Individuals may often misinterpret them. They may hear
sounds that others do not hear and say that they can see enemies coming to kill them. They
may see figures of devil on the wall. Persons with Mental Illness can see things which are not
present or which are not seen by others. They can hear voices from empty spaces; oftenspurious sensations are also reported. Thus, even without any external stimuli they perceive
28
things, and react to them. This is known as "Hallucination". When a person hears some voices,
he/she may in turn start abusing or threatening the imaginary persons. On seeing someone with
a weapon the person may run away to hide himself or attack others. A person, who is
hallucinating, can be seen talking to self, laughing or weeping and wandering on the streets.
e) Memory: A person's memory may be disturbed and as a result family can report forgetting.
Individuals may forget whatever they see, hear or experience within a few minutes. They may
be unable to remember where they have kept common articles of daily use such as money,
clothes, keys, umbrella etc. They may not remember transactions carried out a few days earlier
or people whom they have met a week back. They may lose capacity to remember their past
and may even find it impossible to recall names of their children, where their brothers and
sisters live etc. In severe cases, individual may lose self even in a familiar place
f) Intelligence and judgment: In some mental illness, intelligence and the ability to take decisions
deteriorate. Person can lose the capacity to think clearly and hence may commit mistakes in his
routine work. He/she may not be able to do even simple arithmetic and appear dull. In many ill
persons, the ability to take appropriate decisions in a variety of situations is impaired or lost.
They may take wrong decisions, which can result in difficulties for themselves and others. For
example, they may keep guiet even after seeing a child fall and get hurt.
g) Level of consciousness: In some mental illnesses, due to brain damage there can be
changes in the level of consciousness. The person with mental illness can also become
disoriented about time place and persons.
3 .Changes in personal and social activities:
a) Personal: A person with mental illness can neglect bodily needs and personal hygiene like
washing combing hair, bath or change clothes. He/she s can remain unclean for many days and
not bother even when such neglect causes discomfort. At times they may even soil their clothes
and bed.
b) Social: A person with mental illness behaves strangely with family members, friends,
colleagues and others by insulting abusing or assaulting them. The individual may behave
inappropriately in social situations and embarrass others. He/she may be rude to others
annoying them or resulting in others making fun of him/her.
Mental illness effect the functioning and thinking of the individual, greatly diminishing his/her
social role in the community. In addition because mental illnesses are disabling and last for
many years, they take a tremendous toll on the emotional and socio-economic capabilities of
the people who care for the person with mental illness, especially when the health system is
unable to offer treatment and support at an early stage. Some of the specific economic and
social costs include:
• Lost production from premature deaths caused by suicide.
• Lost production from persons with mental illness who are unable to work for short,
medium and long run.
• Lost productivity from family members caring for the persons with mental illness.
• Reduced productivity from people being ill at work.
• Cost of accidents by people who are psychologically disturbed.
• Supporting dependants of the person with mental illness.
• Direct and indirect expenses of families caring for the person with mental illness.
• Unemployment, alienation and crime in young people whose childhood problems,
e.g., depression, behaviour disorder, were not addressed sufficiently enough for
them to benefit fully from the education available.
• Poor cognitive development in the children of mentally ill parents
• Emotional burden and diminished quality of life of family members.
29
Causes of mental illnesses
Mental illnesses can be caused by a variety of factors as follows:
Changes in the brain. Any change either in structure or functions of the brain can cause
mental illness. Damage to the brain due to any of the following reasons can also cause
mental illness: infections, injury, poor blood supply, bleeding, tumors, substance abuse
for long periods, vitamin deficiencies and untreated epilepsy. Biochemical changes at
level of nerve cells are the causes in a majority of the severe type of mental illnesses
(Schizophrenia, Mood disorders)
Hereditary factors: In a few cases of mental illness, there may be someone else in the
family affected with a similar illness. In most cases however, there would not be
anybody in the family with a similar mental illness. The tendency to develop a mental
illness can be transmitted to an individual but whether the person actually manifests the
illness depends on many other factors.
Childhood experiences: Adequate love and affection, suitable guidance, encouragement
and discipline are all necessary for the healthy growth of a person. If they are not
adequate and there are repeated unhappy experiences in childhood, they can
contribute to development of mental illness later in adult life.
Home atmosphere: Frequent quarrels, misunderstanding and strained relationships
among the family members, lack of warmth and trust among them can have undesirable
effects on the persons. Such an individual when faced with stress and strain, in later life,
can become ill as he lacks the necessary skills to deal with the situation or to control his
emotions.
Other factors: If an individual does not get equal opportunities and facilities to live as an
accepted and respected member-of the society, he/she can develop mental illness.
Poverty, unemployment, injustice, insecurity, severe competition and social
discrimination contribute to development of mental illness.
The causes of mental illness described above can also be groups as predisposing
factors, precipitating factors and perpetuating factors
■ Predisposing factors
Genetic
Trauma at birth
Psycho-social factors in development
■ Precipitating factors
Physical disease
Drugs
Psychological stress
Social changes
Accidents
■ Perpetuating factors
Intrinsic to the disorder
Social circumstances
30
Figure 4.1
The structural model of mental health
Societal structures .
and resources
Social support
and other interactions
Mental
Health
Individual factors
Cultural values
5
31
Session 3 - case studies
Case study - 1
Ramalakshmama is a 30-year-old married woman who has studied upto grade XII, and
was working in a garment factory as a helper. She has complained of dizziness and
headaches for the past one year, but medical investigations revealed no physical
illness. In course of sustained conversations with her, it has come to light that she is
constantly thinking about various things, sleeping badly and occasionally having suicidal
thoughts. She feels tired and not upto house hold chores. Her relationship with her
husband worsened over time. A big cause for his displeasure has been that she has not
borne a child and it has been two years since their marriage. He has been threatening
to marry for the second time. To worsen matters, she also lost her job 3 months back as
she was not able to concentrate on her work. She has no hope of securing another one
given the way she is feeling. Currently she is feeling very lonely and helpless with no
support system and has little hope of improving her situation.
Case Study-2
A 24-year-old married woman witnessed a horrific accident involving a man falling off a
running train. By nature she was an anxious and fearful person. Post witnessing this
accident, her anxiety and fear have increased manifold. She now complains of extreme
fearfulness while traveling in bus or train. She felt a wave of fear every morning when
she traveled to go to her work place. Within a week she started avoiding the train and
started going by bus. Within few days, she developed anxiety while traveling by buses
too. The very thought of traveling would trigger episodes of severe anxiety,
accompanied by trembling, sweating of the palms, feelings of suffocation, and get a
feeling that she would die. Due to these problems she stopped going to work, and even
the thought of going out of the house brought on the same episodes of intense anxiety.
Finally, over a period of two weeks, she started feeling sad, feeling fearful most of the
time, felt a sense of loss of control over her life and began having suicidal thoughts. Her
husband persuaded her to seek help from the counseling center.
Case Study-3
Mrs Geetha, 35 year old housewife, has been complaining of repeated episodes of
heart attacks. She recalls that her problems began 10 years back when she delivered
her only child. The first attack occurred while she was working in the kitchen. She
suddenly felt that there was a dramatic increase in her heart beat. She also felt an
intense stabbing pain in her chest and had difficulty in breathing. She started sweating
and trembling, felt dizzy and was rushed to a physician. An ECG was performed
immediately and was reported to be normal. Since then,
Mrs Geetha has complained
periodically of such episodes of heart attacks with each episode lasting about 15-30
minutes. There have been nearly four episodes every month. During these episodes,
she seeks medical help. Over the past 10 years she has undergone many medical
investigations, each of them reconfirming and reassuring her that she has no cardiac
disorder.
32
After her first few attacks, she has developed a fear of having an attack and not being
able to access medical aid. Since then she avoids crowded places such as banks,
marriage parties and cinema houses, where quick escape might be blocked and
medical aid not easily available. The episodes still occur and are observed more
frequently in those situations which she fears most. Mrs. Geetha recognizes that both
her symptoms and her avoidance behavior are unreasonable and excessive, but
nevertheless they dominate her life. She feels mildly depressed and restless and has
difficulty falling asleep. Her confidence is low, and she is unable to focus on any activity.
Case Study - 4
Mrs K is 45 years old, married for last 25 years. Her relationship with her spouse is
strained and there is a severe marital conflict. For the past five years, Mrs. K has been
having episodes of physical discomfort where she has difficulty in breathing, complaints
of chest pain, sweating, and tremors. She has burning sensation in the chest and
abdomen and feels that she is having heart attack. During this phase of discomfort, she
has intense fear and cannot sit in a place and wants somebody to be with her. Each of
such episodes lasts 5 to 10 minutes. Mrs. K has consulted a heart specialist, who after
series of tests and examinations has reassured her that her heart is healthy. In spite of
this she continues to have instances of discomfort and often visits her family physician
and also approaches different doctors to find a solution. The frequency of such
episodes has increased, affecting her daily routine and has also aggravated the marital
discord.
Case Study-5
Mr. Suresh, 36-year-old and married, working as a mechanic in a private factory, was of
an energetic and pleasant disposition. His family comprised of his wife and two
daughters. One day while returning from his factory, Suresh met with an accident in
which he sustained an injury to his right leg. He was taken to a private hospital where
the orthopedician tried to do restorative surgery. Unfortunately gangrene set-in after the
surgery. Hence the specialist suggested to go for a below knee amputation. Suresh
consented to the surgery after initial refusal. The surgery was done without any
complications and postoperative-period was uneventful. Suresh was discharged within a
week. A fortnight later, when Suresh was brought in for a follow up, he complained of
uneasiness, decreased sleep and body aches. His family reported him to be withdrawn
and irritable with frequent anger outbursts. His wife said that he was often fearful, had
very little interest in pleasurable activities and even indulged in tears at times. She
mentioned that for two days before the consultation, he had spoken of suicidal thoughts.
She revealed that all this had increased since listening to his colleague who mentioned
that Suresh might lose his job on account of his condition. The wife also shared that all
aspects of marital relationship had been affected post the accident. During the
consultation Mr. Suresh started crying and asked the orthopedician for an injection
which would put an end to his life without any pain. He shared a feeling of
worthlessness and being a burden on the family as he couldn’t return to his job. He
expressed helplessness and hopelessness and a deep sense of life being unfair to him.
33
Case Study-6
Lawrence, a 20-year-old boy discontinued his studies as he was not able to pass his 7th
standard since the age of 15. He started working as a helper under a contractor at the
construction sites. He was honest in all his dealings and gave his earnings to his
parents. He had lot of friends where he was living. His evenings were spent in the
company of his friends, playing cricket, football etc. One of his friends was in love with a
girl residing in the neighborhood. His friends used to tease that girl often. One day a
group of 5 youth attacked Lawrence and his friends unexpectedly. Lawrence was also
badly assaulted as he was part of the group. He had a head injury and was
hospitalized. Few weeks later he developed excessive fear and was not ready to go out
of the house. He would scream constantly and sound very abnormal.
Lawrence’s sister speaks of the incident and what followed. “He was an ok boy. Did not
do well in the school and discontinued his studies. He started learning carpentry and the
trainer was also a contractor. Hence, he had no problem in getting work. One day he did
not feel normal. He was disoriented, speaking unnecessary things and behaving
abnormally. We took him to various healers and offered prayers in the church but there
was no improvement. One day he ran away from home. We searched all over but did
not find him. I think after more than two months his brother found him in another part of
the town. When he was brought home, my heart sank and I wept. Every one was in
tears. He was in his underwear and had an old coat on him. Even now if I think of that
scene, some thing happens in my stomach.”
Case Study-7
Mrs Nagarathna, a 55 year old Telugu speaking retired employee from Hyderabad, was
reported to have died in a railway accident. She was run over by a moving train and her
body was found on the railway tracks. As she was often crossing the railway tracks, the
neighbors surmised that she went wrong in her judgment while crossing the tracks on
that day and met with an accident.
A doctor who was a friend of Mrs. Nagarathna, however, spoke to her daughter and
elicited some information regarding her behavior during the past six months. Mrs.
Nagarathna had opted for voluntary retirement the previous year and was not
interested in taking up another job. She would spend her time reading, watching TV and
helping her daughter in law in managing the house. She seemed to enjoy this new
lifestyle for the first six months. However, subsequently her family began to notice
considerable change in her behavior. She seemed worried and tense most of the time
for no apparent reason. She would wake up at 3 in the morning and would find difficulty
in going back to sleep. She tried taking sleeping pills on her own but it did not help her
much. She would feel excessively tired throughout the day. She lost her appetite and
ate nearly half her usual intake. As a result, she lost 10 kilos over a period of three
months. She also complained of constipation very often. She stopped her morning
walks, watching TV and reading books. She would often remark that she had wasted all
her life for the sake of family. She would share her guilt for not saving enough money for
her children. Gradually she started feeling more and more helpless about the lack of
control over her life. She often expressed that life was not worthy to continue, and
expressed death wishes. Finally she decided to end her life by going under the moving
train.
34
Session 4
Types of mental illness: 120 minutes
1. Trainer refers back on the previous presentation of the group and ask
them to identify difference between case vignettes
2. Trainer list down all the responses in the black board
3. Trainer summarizes the discussion through differentiating severe mental
disorders and common mental disorders
4. Trainer gives four case vignettes on depression, anxiety, bipolar affective
disorder, schizophrenia
5. Trainer ask the participants to do a role play based after reading the case
vignettes
6. Trainer invites the group for the role play
7. After each role play trainer summarize with the presentation on the type of
mental illness.
8. Trainer summarizes the discussion with a triangle describing types of
mental illness and with its prevalence.
35
Session 4
Types of mental illness
I. Severe mental illness: It is a severe type of mental disorder in -which patients talk
and behave abnormally. The functions of the body and mind are severely disturbed
resulting in gross impairment of individual and social activities.
II. Common Mental Disorders: Patients show either excessive or prolonged emotional
reaction to a stress situation. They have symptoms like anxiety, fear, sadness, vague
aches and pains and other bodily symptoms. They are aware of their problems and
seek help. They do not have psychotic symptoms.
III. Alcohol and substance dependence: this are generally divided up partly according
to the substance involved (alcohol, opioids, cocaine and etc), partly by clinical
syndrome. The clinical syndromes are of three main kinds, addiction states,
complications of use/abuse, and withdrawal syndromes.
IV. Childhood behavior problems: These are mostly disturbances of behavior and
conduct occurring in stressful family situations or as part of development, manifestation
as abnormal behavior not appropriate to the age of the child.
V. Personality disorders: personality disorder can be thought of as maladaptive
exaggeration of a personal trait. Symptomatically, a personality disorder may appear
very similar to one or other type of the mental disorder. However, where a disease
represents a change from what is normal for the patient concerned, a personality
disorder is normally established by late adolescence and continues more or less
unchanged in to old age.
VI Psychosexual disorders: Psychosexual disorders are of two types: sexual
dysfunction and sexual deviation.
Sexual dysfunction includes any persistent
impairment of the normal patterns of sexual interest or response. Sexual deviation is a
term to any sexual interest or activity that is preferred to, or displaces, adult hetrosexual
interest or behavior, that are unusual and bizarre that violates prevailing social norms of
the society.
VII Organic Mental disorder:
These disorders are caused directly by damage to the structures of brain. The
underlying disease may be in the brain itself or may be in the other parts of the body.
The important symptoms and signs of the disorders are; disorientation to time, place
and person, poor Comprehension, poor calculation, memory deficits, changes in
personality, emotional lability, self neglect and absence of awareness of the same
36
Session 4 b
Severe mental illnesses
Each of us is very individual in our own way. Every individual has different interests and
methods of dealing with different situations in life. Similarly behavior of individuals to life
situations is also not uniform. However, most of the people in one community have fairly
similar ways of thinking (mentally reacting), feeling and behaving. In all communities
there are agreed norms as to what should be considered normal and what should be
considered 'ABNORMAL'. For example, nobody will consider the wearing of colorful
dress to a village get together or a fair as abnormal, but anyone coming with similar
dress to sad occasion will be immediately considered as being abnormal, by almost all
persons.
In the medical sense, any persistent and severe disturbance of thinking, feeling and
behavior is considered abnormal. In the past such conditions were called 'insanity or
melancholia'. Modern science classifies them as PSYCHOSES/severe mental illness. In
popular language they are often wrongly referred to as 'mad' or 'insane'.
Till recent times, persons with severe mental illnesses were feared and managed
harshly by tying up, chaining or locking them in a room. Some also considered mentally
ill persons as holy men and cared for them with respect. In the last 40 years of medical
treatment has become available which can make these ill persons normal so that they
lead a normal life. The following section deals with persons having major mental illness,
their recognition and care. It is estimated that 1% persons in 1000 population suffer
from one or other form of psychoses at any point of time.
It is a common belief among general population that psychoses are not illnesses. They
are thought to be due to religious and supernatural causes. Illness is attributed to
phenomenon like 'ill will of Gods' and 'visitation of evil spirits and souls of dead persons'.
As a result of these beliefs persons with severe mental illness are usually taken initially
to religious healers, magicians, temples instead of medical facilities. It is also thought
that there are no care services to treat people with severe mental illness. It is very
important to recognize and remember that severe mental illness are similar to other
physical problems in that persons, which can recover from them as much from other
physical illnesses. As in the case of all disorders the outcome with treatment varies with
the severity and type of the problems and the time of starting treatment.
The important features are:
1) Loss of touch with reality
2) Symptoms like hallucinations, delusions
3) Neglect of body needs and personal hygiene
4) Socially disruptive behavior like aggression and violence
5) Neglect of work and responsibilities
6) Social isolation
7) Thought disturbances
37
Acute psychosis - in India, a number of studies have shown that about 10% of all
persons with psychosis belong to the category of acute psychosis. This condition is
characterized by:
1. An acute onset (within 2 weeks), presence of associated stress,
2. A typical syndrome characterized by rapidly changing and variable clinical picture.
Complete recovery usually occurs within 2 to 3 months and most often within few weeks
or even days. In view of these features, the treatment of these disorders is very effective
and the duration of treatment is not as long as in schizophrenia.
Schizophrenia - schizophrenia is the commonest of the severe mental illness and the
symptoms of this illness closely correspond to the layman’s concept of madness. It is an
illness, which interferes with individual’s personal and social functioning and if
untreated, can run a chronic stage and disability. Schizophrenia usually starts in the age
group 15-25 years. The onset can be acute or insidious. Some times the onset may be
precipitated by a stressful event. The illness affects both sexes equally and occurs in all
social groups.
The illness is characterized by abnormalities of thinking, perceptions and emotions
resulting in abnormal behavior, action and talk. An individual with schizophrenia has
abnormal ideas and thoughts of various kinds, which the individual believes and are
unshakable (delusions). Ill persons perceive things which really do not exist (i.e. hears
voices and sees visions which are non existent - (hallucinations).
Bipolar affective disorder - This type of mental illness is also called “Affective
psychosis” because the primary abnormality in this illness is one of affect (emotion
mood). The disturbances in mood occur both in quality and quantity and ranges from
extreme sadness to extreme happiness. The mood disturbances occur in episodes of
either happiness (mania) or sadness (depression). These episodes can also occur
alternatively, this is called Bipolar Affective Disorder.
Some observations on severe mental illness :
•
•
•
•
•
•
•
•
Major mental disorders begins in young adulthood
It has potential to be chronic and or disabling
1% of the population are having diagnosable severe mental illness
High usage of mental health services
Risk for home less ness
Heavy emotional and financial burden for the caregivers
Largely un treated
The illness results in social and occupational dysfunction
38
Session 4 c
Common mental illnesses
Common mental illness/Neuroses are a group of minor mental disorders, which are not
easily defined. Unlike in severe mental illness/psychoses, persons suffering from
common mental disorders do not lose touch with reality and they are able to meet the
ordinary demands of every day living. They generally have a good understanding of
their problems while they do not cause much of distress to others in the family, but more
distress to the person himself/herself. They themselves experience varying degrees of
personal responsibilities, work and other usual social situation though disturbed to
varying extent, usually does not disable the person completely. The disability caused is
generally related to the degree of personal suffering the patient experience.
The basic and predominant features of common mental illness are mental tension and
worry. All people get tense or worried from time to time especially when faced with
difficult problems. However, they are able to cope with the situations and overcome their
tensions or worry with passage of time. If the tension, worry is too much in intensity or
prolonged in duration, they tend to interfere with the person’s sense of well being and
disturb the normal functioning. Many persons with common mental illness, basically
have feelings of inadequacy and inferiority (lack of confidence) which lead them to
perceive common every day problems as difficult and threatening. This constantly
produces tension and worry and these individuals prefer to avoid facing these problems,
ultimately resulting in a multiplicity of physical or psychological complaints.
Majority of individuals with minor mental illnesses, there can be stressful factor either
precipitating or perpetuating the symptoms. The stress can be in the form of a
disturbance in relationship with a person, a family quarrel, an unhappy marriage,
difficulty at work place, persistent financial problems, serious/chronic physical illnesses
in family or a death in the family or a social set back.
It would be easy to recognize that all individuals cannot escape from suffering, from
some degree of mental tension, unhappiness. They experience symptoms in the
presence of problems of every day life, at one time or the other. However in the case of
person with common mental illness, these tensions, worries, unhappiness and the
consequent symptomatology become part of their life style, leading to constant feelings
of insecurity and a need for support from others. The exact clinical presentation of
common mental illness can markedly vary from one person to another.
Types of common mental illness:
Depression:
We all might have experienced feeling of unhappiness sometimes or the other and also
intense grief following death of a close relative or a family member. But these feelings
go off with time and usually do not require any treatment and also would not cause
significant disturbances in the day-to-day affairs. But persons with depressions would
require appropriate care services for improving their functioning ability. Depression is
one such disorder that hampers the quality of life of an individual remarkably and can
lead to life-threatening complications such as suicide. It is therefore important for a
clinician to recognize the presence of this condition in people during their consultations
and provide adequate care services for the recovery. Generally, the outcome of care
39
services is good if the condition is detected early and referred for appropriate care
including counseling and psychotherapy. There have been various studies among
different populations measuring the risk of major depression; generally, the results all
over the world are more or less similar. The lifetime prevalence of depression is 15.3%.
Most of them reported to have recurrent episodes. In general depression is higher in
women than men. About 18 to 23% of all women and 8 to 11% of all men have
depressive episodes at some time. 6% of those women and 3 % of those men require
hospitalization at some time.
Anxiety In our day to day work in the communities we would have seen substantial number of
people having symptoms of anxiety and depression. Generalized anxiety disorder is a
condition that is commonly seen in people. According to a rough estimate more than
30% of patients attending medical or surgical problems have one or more symptoms of
anxiety or depression. However, it is often unrecognized and under diagnosed because
of many physical symptoms leading in search of a physician to attend to their physical
illnesses. The characteristic features is excessive anxiety and worry (apprehensive
expectation of negative outcomes) about various events and activities such as concerns
about family and interpersonal relationships, work, school, finances and health. The
person suffering from generalized anxiety disorder finds it difficult to control the worry
and present for most part of the day.
Phobic Disorders:
Phobia is defined as 'an irrational fear that produces conscious avoidance of the feared
object, activity or situation'. Either the presence or the anticipation of the phobic entity
elicits severe distress in an affected person who usually recognizes that the reaction is
excessive. Phobic reactions usually disrupt the ability to function in life. The sufferer
would know that his fear is absolutely silly and there is no reason for fear but still he
cannot help avoiding the object or situation. The common feared situations or objects
include leaving home, crowds, public places, pet animals, speaking in public, entering
small places like lift.
Panic disorder:
Panic disorder draws its name from the Greek god pan, god of flocks. Pan was known
for suddenly frightening animals and humans out of the blue. The spontaneous ‘out of
the blue’ character of panic attacks is the principal identifying characteristics of panic
disorder and central to its recognition. Often people present with the complaints of heart
attack, when investigated, reveals no abnormalities. Panic disorder is a chronic but
treatable problem, associated with a high degree of social and work impairment, poor
quality of life, and frequent relapses. Often unrecognized, it is associated with excessive
use of medical services.
Post Traumatic Stress Disorder:
After exposure to a traumatic life threatening accident or natural disaster such as
tsunami, earth quakes, floods and manmade disaster like bomb blasts and riots and etc.
Some people involved in or witnessing it develop a group of symptoms termed as acute
stress reaction. These symptoms usually resolve gradually over a period of one month.
In some susceptible individuals these symptoms persist beyond one month and cause
severe distress and functional impairment.
40
Adjustment disorders:
The development of psychiatric symptoms in the context of stress is virtually a universal
experience. An adjustment disorder is defined as development of emotional or
behavioral symptoms in response to an identifiable stressor(s) occurring within a month
of the onset of the stressor(s) and the duration of symptoms usually does not exceed 6
months. These symptoms or behaviors are clinically significant as evidenced by either
of the following:
1) Marked distress that is in excess of what would be expected from exposure to the
stressor.
2) Significant impairment in social, occupational or educational functioning.
Obsessive-compulsive disorder (OCD):
Many of us have habits and routines, which help to organize daily lives, but if a person
develops a pattern of behavior which takes too much time and interferes with daily lives,
then he/she is said to have OCD. OCD is an intriguing and often disabling syndrome
characterized by two distinct phenomenon’s obsessions and compulsions. Obsessions
are unwanted and intrusive ideas, images and impulses that run through the person’s
mind over and over again. Sometimes these thoughts come only once in a while and
are only mildly annoying, but at other times the thoughts comes constantly and cause
significant distress. A compulsion is a behavior that is performed in response to the
obsessions. Individual put this thoughts in to actions as per the rules he has made for
himself/herself in an attempt to control the distress causing by the obsession. People
with OCD hide their problem to avoid embarrassment. Often this people are labeled as
perfectionist/hygienic person. The studies established it has being a fairly common
syndrome with a prevalence of over 2%.
41
Session 5
Mental illness and mental retardation: 30 minutes
1. Trainer invites participants to share their experience of working with children with
mental retardation
2. Trainer invites participants to share their view on “is mental retardation a mental
illness”
3. Trainer invites participants to share their view on differences between mental
illness and mental retardation
4. Trainer summarizes the discussion with presentation on the difference between
mental illness and mental retardation.
42
Session 5
Mental Retardation and Mental Illness: What’s the Difference?
Mental Retardation
Mental Illness
1. Mental retardation* refers to subaverage
intellectual functioning.
1. Mental illnesses are medical conditions that disrupt
a person’s thinking, feeling, mood, ability to relate to
others, and daily functioning. Just as diabetes is a
disorder of the pancreas, mental illnesses are medical
conditions that often result in a diminished capacity for
coping with the ordinary demands of life. Mental illness
has nothing to do with intelligence.
Mental retardation can be classified as profound,
severe, moderate, mild and borderline mental
retardation.
Mental illness are mainly classified as severe mental
illness and common mental illness
2. Mental retardation is a condition, hence no
treatment for recovery, they can be trained for
daily living skills
2. Mental illness is an illness, if identified and provide
appropriate care services would recover from illness
and manage his/her life.
3. Mental retardation refers to impairment in
social adaptation.
3. A person with a mental illness may be very
competent socially, but may have a character disorder
or other aberration.
4. National incidence: 3% of the general
population.
4. Mental disorders fall along a continuum of severity.
Even though mental illness disorders are widespread
in the population. 1 % of the population have severe
mental illness, 5-15% of them have common mental
illness
5. Mental retardation is present at birth or occurs
during the period of development.
5. Mental illnesses can affect persons of any age, race,
religion, or income. Mental illnesses are not the result
of personal weakness, lack of character, or poor
upbringing. Mental illnesses are treatable. Most people
diagnosed with a serious mental illness can experience
relief from their symptoms and manage symptoms by
actively participating in an individual treatment plan.
6. In mental retardation, some degree of
intellectual impairment can be expected to be
permanent.
6. Individuals with mental illness and their families if
provided support and services can recover from illness
and would be able to manage his/her life
7. A person with mental retardation can be
expected to behave rationally at his/her
functional level and not to his/her age.
7. A person with mental illness may vacillate between
normal and irrational behavior.
8. People with mental retardation can also
experience different types of mental illness with
symptoms such as hallucinations or severe
depression, secondary to the condition of mental
retardation.
8. The term mental illness covers a wide variety of
symptoms that may indicate that someone is in
emotional trouble, including: excessive moodiness,
suspicion and mistrust, or poor emotional control.
43
Session 6
Organizing care services
a. Mental health Interventions
90 minutes
1. Trainer divided participants to go back to same groups (role plays and case
vignettes)
2. Trainer refer back to the role plays and the case vignets and ask the participants
to make a problem tree
3. Trainer invites participants to make presentation on the problem tree
4. Trainer ask larger group to share their thoughts on the possible interventions to
improve the quality of life of people with mental illness and their families after
each presentation
5. Trainer invites participants to share their thoughts on how to change the attitude
of the community members
6. Trainer invites participants to summarize the list of the interventions
7. Trainer summarized with their experience of working with people with mental
illness in the community
8. Trainer categorizes the list of the interventions in to what can community worker
do and what support structures are needed for the care services from external
sources.
b. District mental health programme and National mental health programme:
30 minutes
1. Trainer shares about the objectives of National Mental health programme of
2.
3.
4.
5.
1982
Trainer makes presentation of the objectives of District mental health programme
Trainer makes a presentation of DMHP- Bellary model to 10th five year plan
Trainer distributes paper on the 11th five year plan and mental health programme
Trainer invites participants to brainstorm How NGOs can take up complementary
role in DMHP programme.
c. Multi dimensional approach:
60 minutes
1.
2.
3.
4.
5.
Trainer divides participants in to three groups
Trainer distributes the article on Multi Dimensional Approach
Trainer invites participants to read the article on multidimensional approach
Trainer invites the group to share the summary of the presentation
Trainer sums up the discussion sharing his/her experience of implementing
community mental health and development programme.
44
Session 6
Mental health care services
It has been seen that mental illnesses are of different types. Each of them affects the
individual in varying degrees. Their duration also varies. 8o the available treatments
also vary. It was often thought that no specific treatments are available for mental
illnesses. This is not correct. This wrong notion occurs because people commonly
believe that admission to a mental hospital, for lifetime, is the only means available to
care for persons with mental illness. This belief is also the result of seeing only the
chronically ill patients. In the last 50 years specific treatments for selected mental
illnesses are available which are as effective as the treatments for physical illnesses like
tuberculosis, leprosy, malaria and typhoid fever
The different types of treatment and healing practices are:
1. Medicines: If treatment is started early and is continued regularly complete recovery
is possible. These medicines are available in the form of tablets, capsules, syrups,
and injections. Medicines are available for all severe and common mental disorders.
2. Electroconvulsive treatment (ECT): It is commonly believed to be "the final
treatment" for all types of mental disorders when no other treatment helps in
recovery. However, it is one of the effective and safe methods of treatment for some
specific mental disorders when given appropriately by a team of specialist. In few
patients it can bring about dramatic recovery, e.g., as in severe depression. The
person/ family need to give consent for taking ECT. It is given friction of second
under the influence of anaesthesia.
3. Psycholoqicai help (psychotherapy): Individuals faced with stressful situations
experience psychological distress. Such persons can be helped by simple methods
like listening to their difficulties, talking to the family as a group, bringing about
change in their life situations. These efforts can result in greater harmony in their
lives and thus improvement in their symptoms.
a. Family Therapy:
Family therapy is a branch of psychotherapy that works with
families and couples in intimate relationships to nurture change and development. It
tends to view these in terms of the systems of interaction between family members. It
emphasizes family relationships as an important factor in psychological health. As such,
family problems have been seen to arise out of systemic interactions, rather than to be
blamed on individual members. Family therapists may focus more on how patterns of
interaction maintain the problem rather than trying to identify the cause, as this can be
experienced as blaming by some families. It assumes that the family as a whole is
larger than the sum of its parts. Family therapy may also be used to draw upon the
strengths of a social network to help address a problem that may be completely
externally caused rather than created or maintained by the family.
Family therapy has been used effectively where families and or individuals in those
families experience or suffer serious psychological disorders (eg schizophrenia anxiety
depression, personality disorders, Attention deficit hyperkinetic disorders, additions and
eating disorders.
45
b. Cognitive behaviour therapy: CBT can help you to change how you think
("Cognitive") and what you do ("Behaviour)". These changes can help you to feel better.
Unlike some of the other talking treatments, it focuses on the "here and now" problems
and difficulties. Instead of focusing on the causes of your distress or symptoms in the
past, it looks for ways to improve your state of mind now. CBT can help you to make
sense of overwhelming problems by breaking them down into smaller parts. This makes
it easier to see how they are connected and how they affect you. These parts are:
■
■
■
■
■
A Situation- a problem, event or difficult situation
from this can follow:
Thoughts
Emotions
Physical feelings
Actions.
Each of these areas can affect the others. How you think about a problem can affect
how you feel physically and emotionally. It can also alter what you do about it.
This is a simplified way of looking at what happens. The whole sequence, and parts of
it, can also feedback like this:
Situation
A
7
Thoughts
Actions
Feelings
This "vicious circle" can make you feel worse. You can start to believe quite unrealistic
(and unpleasant) things about yourself. This happens because, when we are distressed,
we are more likely to jump to conclusions and to interpret things in extreme and
unhelpful ways.
CBT can help you to break this vicious circle of altered thinking, feelings and behaviour.
When you see the parts of the sequence clearly, you can change them - and so change
the way you feel. CBT aims to get you to a point where you can "do it yourself", and
work out your own ways of tackling these problems.
c. Group therapy: In group therapy approximately 6-10 individuals meet face-to-face with
a group therapist. Members are encouraged to give feedback to others. Feedback
includes expressing your own feelings about what someone says or does. Interaction
between group members are highly encouraged and provides each person with an
opportunity to try out new ways of behaving; it also provides members with an opportunity
for learning more about the way they interact with others. It is a safe environment in which
members work to establish a level of trust that allows them to talk personally and
honestly. Group members make a commitment to the group and are instructed that the
content of the group sessions are confidential. It is not appropriate for group members to
disclose events of the group to an outside person.
46
As the group members begin to feel more comfortable, the group member will be able to
speak freely. The psychological safety of the group will allow the expression of those
feelings which are often difficult to express outside of group. The group member will begin
to ask for the support needed. The group member will be encouraged to tell people what
is expect of them. In a group, the member probably will be most helped and satisfied if
given opportunity to express and talk about their feelings.
d. Couple/Marital therapy: Couples therapy is a form of psychological therapy used to
treat relationship distress for both individuals and couples. The purpose of couple
therapy is to restore a better level of functioning in couples who experience relationship
distress. The reasons for distress can include poor communication skills, incompatibility,
or a broad spectrum of psychological disorders that include domestic violence,
alcoholism, depression, anxiety, and schizophrenia. The focus of couple therapy is to
identify the presence of dissatisfaction and distress in the relationship, and to devise
and implement a treatment plan with objectives designed to improve or alleviate the
presenting symptoms and restore the relationship to a better and healthier level of
functioning. Couples therapy can assist persons who are having complaints of intimacy,
sexual, and communication difficulties.
Rehabilitation: Certain proportion of persons with mental illness may not recover
completely and left with longstanding impairments and disabilities. Such persons would
benefit from rehabilitation programs, which include simple measures like involving them
in recreational activities, teaching them simple things repetitive type of jobs, (eg. basket
making, agarbathi making etc), social skill training, communication training, and
including them in the daily household routines.
47
Session 6 b
Family interventions in community mental health programme:
What are Family Interventions?
During family visits, a development worker provides support and understanding of the
illness for the affected individual and family members. Person with mental illness and
their caregivers are consulted and involve them for the planning for assessment,
diagnose and care services. This support helps the family in understanding of the
illness. Intervention helps the person in gaining insight into the problems. Family
interventions also help the family to cope with a chronically mentally ill member as well
as reduce the burden faced by the families.
Why involve the families in the care of their mentally ill members?
There are a number of reasons for this:
1. Family members and relatives are the main care givers of people with mental illness.
2. Family supervises the care services like medication intake, follow up of psycho social
intervention and provide emotional, social and financial support for the affected
member.
3. To deal with the fears and anxieties about the causes of mental illness and the
affected member’s future.
4. The family’s lack of understanding of the resource available for treating their affected
family member, lead them to helpless situation and force them to get involved in human
rights violation.
5. Families may feel they are contributing to the affected member’s problems, feel guilt
and would be more supportive. They can become defensive in the treatment process.
6. The presence of an affected member changes the routine of the family life. The family
members have extra household chores, as the affected member is unable to contribute.
Trying to keep the family life as normal as possible while simultaneously trying to help
the affected member is going to be frustrating more tedious/strainful. Due to caring their
mentally ill family member would loose his or her livelihood opportunities.
7. The family may find the affected member’s behaviour embarrassing and painful. They
may avoid their normal socialization with others due to the stigma of having a mentally
ill member, leading to self isolation of the family.
8. Families may feel angry with the affected member especially when they feel that the
affected member is ‘lazy’ or not trying to control their behaviours due to the negative
symptoms.
48
9. Families may experience severe stress, or marital discord or depression associated
with living with this illness, requiring attention from the mental health professionals for
their improving mental health.
10. The probability of the affected member relapsing is greater when the family’s
behaviour with them tends to be over-involved, hostile, critical and dissatisfied
11. The environment in which person lives would contribute towards the prognosis of
the illness.
12. Due to the mental illness in one of the family member, families would experience
burden, it is seen at two levels, subjective and objective burden:
a) What mental illness means to the family constitutes the subjective burden. It includes
a sense of defeat, feelings of guilt, inadequacy, helplessness, confusion, hopelessness
anger, disappointment and depression following the realization that the affected
member is not like a normal individual like his or her fellow beings in the community. All
their dreams set on the individual been unfulfilled because of the mental illness.
b). Objective burden such as decline in the economic status, as poverty is the cause
and consequence of mental illness, (expenses on medication, hospitalizations, travel
etc, and loss of livelihood opportunities for the affected person as well as the family
member/ sleep disruption, interference’s with daily routines in the family, disruption of
family’s leisure time, difficulties in communicating with the affected member, strained
family relationships and reduced social supports etc.
Why families need social support ?
Families with mentally ill member have fewer people to support because of social
stigma and families isolating themselves. Families need to turn for emotional or practical
support from their networks which includes Immediate family members, neighborhoods,
extended families, peer group, self help groups, federations, caregivers groups, care
givers associations, community based organizations, NGOs, volunteers, staff of the
NGOs, panchyaths, PHCs, health workers and etc.
The advantages of having social contacts are:
a) Can be useful as temporary distractions from experiencing the pain of having a
severe mentally ill member.
b) They provide general support and recreation to help the family members relieve their
tensions.
c) Prevents the family member from focusing and spending too much energy on the
affected member, and
d) Provide support in times of crisis.
e) Care givers groups and self help group helps them to ventilate their feelings,
accepted as they are homogeneous groups
49
f) Caregivers forum gives platform for them to raise their collective voices would help
them for advocating for their rights
How effective are Family Interventions?
Family interventions designed to reduce the risk of relapse developed as a result of the
burden experienced by the family members after hospitalization and in the treatment
process. Many research studies, and the experience of Basic Needs India has revealed
that a substantial reduction in relapse rates are due to family interventions and home
based support given by the field staff. Because of the clear relationship between
expressed emotion and relapse, the interventions concentrate on diminishing the level
of expressed emotion through education on the illness and care process, creating a
platform for expressing their problems in a homogeneous groups, dealing with the side
effects and negative symptoms during the home visits, helping families to have realistic
expectations from their mentally ill family member, encouraging, consulting and
engaging the mentally ill in the care process, supporting caregivers to deal with their
problems would be the focus of family interventions in community mental health and
development programme.
What does Family Intervention involve?
\Ne will be seeing the families and the affected person during:
a) When the affected member is acutely symptomatic or relapsed.
b) When the affected member is in the recovering phase.
c) During follow-ups when the affected member is maintaining well on treatment.
As the families that you meet may be in different phases of the illness, they may have
different needs and expectations. The needs of the family per se will differ from that of
the affected member’s.
1.
2.
3.
4.
5.
6.
Treatment for PWMI - support for the travel and medicines.
Dealing with negative symptoms.
Referral services.
Psycho education.
Need for skill training for taking up profession.
Economic empowerment needs (Housing, BPL card, Voters ID, Construction
workers ID, Bus pass, Train pass, Disability ID card, Pension for persons with
mental illness, Old age pension, Widow pension
7. Day care/work therapy centers for PWMI.
8. Institutional care for PWMI - especially families of single parent and aged
parents.
9. Support for general health.
10. Legal support related to property rights/separation.
11. Financial assistance from banks.
Once the person with mental illness had been identified in the community, the field
worker starts working with the family, understanding the problems, assessing the
situation, differentiating with mental retardation and stress. Field workers would provide
50
information about the available services for treating people with mental illness. The field
staff also would encourage the families to attend the caregivers meeting, or meeting
other families having similar experiences so that they can get convinced about the need
for regularizing treatment.
The field staff would build rapport with the affected persons; consult him to understand
his or her needs. Educate the family about the illness and guide them or escort them for
consulting mental health professional for assessment diagnosis and treatment services.
The field staff would educate them about the illness, and would inform them about the
medicine intake. Field staff would visit the families, educate them about side effects,
share his experiences of dealing with side effects, if necessary would refer back to the
mental health professional for managing side effects. The affected person would be
encouraged to take up responsibilities at home, motivate the families for involving in
productive work along with the medicines.
Once the affected person and the family feels confidence of involving in productive work
(household activities). Encourage them for going back to the previous work what he or
she was doing (prior to illness). Incase if it becoming difficult, than encourage them for
involving in income generation activities like agricultural work, goat/cow/ramlamb
gracing, skilled work.
51
VAX ACO
Session 6 c
National Mental Health Programme (NMHP) 1982
The huge country like us lack mental health policy, instead we have National Mental
Health Programme. The National Mental Health Program is the outcome of the
developments in providing mental health care through different methods as well as the
overall goals of the health care in general. The Government of India has launched the
National Mental Health Programme (NMHP) in 1982, keeping in view the heavy burden
of mental illness in the community, and the absolute inadequacy of mental health care
infrastructure in the country to deal with it. The formulation of NMHP in 1982 was a
milestone in the history of mental health care.
The objectives of the NMHP program are:
> To ensure availability and accessibility of minimum mental health care for all in
the foreseeable future, particularly to the most vulnerable and underprivileged of
the population
> To encourage application of mental health knowledge in general health care and
social development.
> To promote community participation in mental health services development and
to stimulate effort towards self -help in the community.
The specific approaches suggested for the implementation of the NMHP are:
> Diffusion of mental health skills to the periphery of the health service system
> Appropriate appointment of tasks in mental health care
> Equitable and balanced territorial distribution of resources
Integration of basic mental health care with general health services
> Linkage to community
Progress of the NMHP
From the time of the formulation of the NMHP in August 1982, in the last two decades
the following initiatives and activities have been taken up in districts where the district
mental health programme has been implemented:
> Sensitization and involvement of state level programme officers
> Workshops for voluntary agencies
> Workshops for mental health professionals namely psychologists, psychiatric
social workers and psychiatric nurses
> Training programmes in public mental health for programme managers
> State level workshops for the health directorate personnel, development of
models of integration of mental health into primary health up to the district level
Preparation of support materials in the form of manuals, health records for
different types of health personnel and health education materials
> Training program for teachers of undergraduate psychiatry
> Initiation of district mental health programme in 28 districts of 22 states
> Expansion of district mental health programme for 100 districts with the
budgetary allocation of rupees 190 crores in the 10th five-year plan (2002-03 to
52
2006-07) and 1200 crores been sanctioned in 11th five year plan to implement
DMHP prorgamme.
> Expansion of district mental health programme to all the districts in the 11th five
year plan.
The District Mental Health Programme (DMHP)
The DMHP, which operates as part of the National Mental Health Programme was
launched in 1996-97 in four districts. By 2000 the DMHP was extended to 22 districts in
20 States and Union Territories and by 2002 the DMHP further extended to 27 districts
in 22 States and Union Territories, providing for services to over 40 million of the
population. In the 10th five year plan period the government has announced the
programmes extension to 100 districts across the states, with a total budget outlay of
200 crore rupees, in 11th five year plan has allotted nearly 1300 crores for mental health
services, agreed to implement district mental health programme in 500 districts through
out India over a period of 5 years. The child mental health issues been given
importance, and money for NGO’s for initiating mental health services been made
available in the current five year plan.
There have been many barriers to reach the goals set out in the 1982 document. The
goals were too ambitious to begin with and sufficient attention was not paid to all
aspects of implementation of NMHP. The other important barrier has been the lack of
funding. Though NMHP came up in 1982 the subsequent three five years plans did not
make adequate funding allocation. Further even the funds allotted were not fully utilized.
It was only in the 9th Five-year plan that a substantial amount of Rs 28 cores was made
available and it was projected to be Rs 190 cores in the 10th Five-year plan and in huge
jump in 11th five year plan.
The critical review of District Mental health programme reveals that:
a. There was lack of administrative clarity to utilize the allocated funds. The
programme looked good on paper, but was extremely unrealistic in its
targets, especially considering the available resources of manpower and
funds for its implementation.
b. The approach was top down and did not take into consideration the
ground realities. The poor functioning of the primary health care in India in
general as well as the poor morale of the health workers not taken into
account. A structure that was attending to given tasks so inadequately
would certainly be unable to absorb new targets of integration.
c. The DM HP continues to be the extension of professionals rather than
integration of mental health with primary care
Even though, the Government of India has sanctioned DMHP to all the districts in the
11th five year plan. The districts are yet to implement the programme and to appoint
required mental health professionals for the programmes. It has to be noted that a few
districts do not have psychiatrists and the facilities in the district hospital to support the
mobile team of the district mental health programme.
53
National Health Policy- 2002
The 2002 National Health Policy (NHP 2002) refers twice to mental health. In its
assessment of the current scenario, Section 2.13 states that: 'Mental health disorders
are actually much more prevalent than is apparent on the surface. While such disorders
do not contribute significantly to mortality, they have a serious bearing on the quality of
life of the affected persons and their families. Sometimes, based on religious faith,
mental disorders are treated as spiritual affliction. This has led to the establishment of
unlicensed mental institutions as an adjunct to religious institutions where reliance is
placed on faith cure. Serious conditions of mental disorder require hospitalisation and
treatment under trained supervision. Mental health institutions are woefully deficient in
physical infrastructure and trained manpower. NHP 2002 will address itself to these
deficiencies in the public health sectoh.
Section 4.13 states the policy prescription towards mental health: ‘NHP 2002 envisages
a network of decentralized mental health services for ameliorating the more common
categories of disorders. The programme outline for such a disease would involve the
diagnosis of common disorders, and the prescription of common therapeutic drugs, by
general duty medical staff.
The proposed National Health Policy outlines the prioritized agenda for extending within
a pragmatic time frame basic mental health care facilities to all sections of the
populations across the country by the year 2020.
54
Session 6 d
Eleventh Five Year Plan
National Mental Health Programme
3.1.171. A multipronged strategy to raise awareness about issues of mental health and
persons with mental illness with the objective of providing accessible and affordable
treatment, removing ignorance, stigma and shame attached to it and to facilitate
inclusion and acceptance for the mentally ill in our society will be the basis of the
National Mental Health Programme (NMHP). Its main objective will be to provide basic
mental health services to the community and to integrate these with the National Rural
Health Mission. The programme envisages a community and more specifically family
based approach to the problem.
3.1.172. The Plan will strengthen District Mental Health Programme (DMHP) and
enhance its visibility at grass root level by promoting greater family and community
participation and creating para professionals equipped to address the mental health
needs of the community from within. It will fill up human resource gap in the field of
psychiatry, psychology, psychiatric social work and DMHP. The plan will strive to
incorporate mental health modules into the existing training of health personnel. It will
also harness NGOs’ and CSOs’ help in this endeavour, especially family care of
persons with mental illness, and focus on preventive and restorative components of
Mental Health. The Eleventh Five Year Plan, recognizing the importance of mental
health care, will provide counseling, medical services and establish helplines for people
affected by calamities, riots, violence (including domestic) and other traumas. To
achieve these, a greater outlay will be allocated to mental health.
3.1.173. During the Eleventh Five Year Plan, the Re-strategised National Mental Health
Programme will be implemented all over the country with the following objectives:
• To recognize mental illnesses at par with other illnesses and extending the scope of
medical insurance and other benefits to individuals suffering with them
• To have a user friendly drug policy such that the psychotropic drugs are declared as
Essential drugs.
• To give greater emphasis to psychotherapeutic and a rights based model of dealing
with mental health related issues
• To include psychiatry and psychology, and psychiatric social work modules in the
training of all health care giving professionals
• To empower the primary care doctor and support staff to be able to offer psychiatric
and psychological care to patients at PHCs besides educating family carers on core
aspects of the illness.
• To improve public awareness and facilitate family-carer participation by empowering
members of the family and community in psychological interventions.
• To provide greater emphasis on public private participation in the delivery of mental
health services.
55
• To upgrade Psychiatry departments of all Medical colleges to enhance better training
Opportunities
• To improve and integrate mental hospitals with the whole of health delivery
infrastructure that offer mental health services thus lifting the stigma attached
• To provide after care and lifelong support to chronic cases.
• 6.153. Mental Health of Children is an issue that the Eleventh Plan will fund and take
up on priority basis. Counsellors will be appointed in all schools and helplines will be set
up especially during exams, (pg 224, Vol. 2)
•1.19 Address urgent mental health needs of women and increase and upgrade state
support services for women and girls (Vol. 1)
• 6.61The Eleventh plan is committed to mitigating the negative impact on women of
displacement due to natural or man-made calamities, incidents of communal violence or
social upheaval and development projects. It will formulate gender sensitive relief and
rehabilitation policies; (pg 203, Vol. 3)
• 3.1.203 Providing humane Mental Health services (Pg 107, Vol. 2)
The following aspects of the NMHP require attention during the 11th Five Year Plan:
•
•
•
•
•
•
The overall effort should be to create structures that will meet the long-term
mental health programme development in the country, as against the focus on
only rapid expansion of the current models of care.
A system of support and supervision, along with evaluation should be the
foundation of the programme.
There is a need for a national level initiative for human resource development for
mental health care.
Consolidating the different models of care by systematic evaluation, specifically
the DMHP, the school-based interventions, the suicide prevention programme,
substance abuse programmes, family support initiatives, and engage the private
stakeholders within the context of a national mental health programme.
There is a greater need to use the mass media and information technology to
spread the mental health information to the total population.
Attention to the mental health impact of rapid social change, urbanization and
changes in the family life and to develop corrective and humane interventions to
address these effects.
56
Programme Component
10th Five Year Plan
(INR in millions)
11th Five Year Plan
(INR in millions)
D.M.H.Ps
775
6800
Modernisation of Mental Hospitals
600
Nil
Strengthening of Medical Colleges
375
3210*
IEC & Training
100
750
Research
50
Nil
School Mental Health Programme
Nil
2230
0
Monitoring
Nil
150
NGOs
Nil
100
Total
1900
11430
National Mental Health Programme- Budget Allocation
* “Manpower Development”
57
Session 6 e
A Multi Dimensional Approach to Mental Health Promotion
Statistically serious mental illness affects one percent of the population (and a much
larger percentage affected by minor mental illness). However at the community level their
visibility is low as onlyl or 2 affected persons present in a village. Being marginalized by the
pervasive stigma against mental illness and by their own diffidence, mentally ill persons and
their care givers have not been very articulate about their 'needs and rights' in India at a larger
level. In recent times there is increasing interest in this issue to some extent stoked by public
interest litigation (by the NGO SAARTHAK following the Erawadi tragedy in 2001), egging the
reluctant public health structure to begin responding to the needs. However, the present
situation is quite unsatisfactory in the different areas of policies, programs, models of care
adopted, community attitudes and supports and family level awareness and capacities in
relation to the issue of mental illness.
Multidimensional factors affecting quality of life of the mentally ill persons, in India.
Policy and Program level.
The Mental Health Act of 1987 though signifying a positive policy mindset (where mentally ill
people were viewed as requiring treatment and care and not as criminals), however its base in
institutional care makes it ineffectual in meeting mentally ill peoples needs. The inclusion of
mentally ill people in the Persons with Disability Act 1995' is to all purpose peripheral and more
like an after thought
There is no access to "medical care' for the large majority of persons affected. The allopathic
and institutional approach to mental health in the national program has resulted in medical care
and support resources being concentrated in the major cities. The plight of the public and
private run institutions have come up for critical scrutiny by the NHRC and the judicial system.
However even these rudimentary facilities are unavailable at the periphery. Many of the
headquarters towns of the 500 odd districts in India do not have qualified mental health teams,
or availability of medications. The recently launched District Mental Health Program-DMHP
(extended to 22 districts in 2000 in the first phase and to spread to 100 districts in the 10th plan
,2003-2007, and to all districts in 11th five year plan) with a budget outlay of 1300 crore rupees,
is yet to show results at the ground level. Data on the 3rd phase districts chosen are not yet
available. It would appear in keeping with the problems affecting the public health system at
large, the benefit to the clients; even in DMHP districts are likely to be low. Resources being
likely to be cornered by the medical establishment themselves, rather than over all development
of the individuals.
Beyond medical care the important needs (of the mentally ill persons and their caregivers) for
'welfare support measures' and 'livelihood generation' is not addressed at all. Similarly there is
no nationwide 'awareness and education effort' directed against the pervading stigma and for
generating community and family level solidarity.
Community Level:
The stigma against mental illness results in marginalization, excluding them from income
earning opportunities, social recognition acceptance and making them vulnerable to physical
harassment and exploitation. This is compounded by the gender discrimination existing,
resulting in mentally ill wives being rejected by their husbands, affected women's inheritance
being usurped and the local level opinion groups promoting suppressive dynamics against
women.
Family Level:
58
Hostile family dynamics play an important role in the generation and maintenance of mental
illness, (this is an area requiring further researching in India). Often the key caregivers are
overburdened or themselves require physical and emotional supports. Another feature is that of
mentally ill people becoming destitute, with family not able or willing to look after them. A not
uncommon (though not understood) factor is the contribution to mental illness of sexual
exploitation within the family.
Individual level:
Lack of access to quality health care and follow-up services for the side effects, leads to the
high dropout rates from the treatment. Large numbers of individuals who could have been
stabilized with drugs are remaining unmanageable for this reason. Beyond the bio-medical
inputs, individuals have a variety of psychological needs, which are not getting addressed.
Beyond both these aspects there is a lack of recognition of individuals ability to help
themselves, given some critical supports.
Multi Dimensional Approach to Mental Health Promotion.
In the 'developmental model' of mental health professed and promoted by Basic Needs India,
we see the need for changes at all of the above mentioned levels.
Policy and Program :
o
Mental illness and health is a developmental issue and not just a medical problem. Hence it
needs to be addressed wholistically, in policies and programs. Within the health sectoral
interventions, the potential for contribution of the various systems of medicine/health, needs to
be evaluated scientifically. Where found appropriate they should be encouraged, so that people
can choose the system they have faith in, assured of its quality.
Mental health care and medications need to be accessible to needed individuals through the
PHCs, GPs and Voluntary Sector agencies. This would require appropriate professional training
interventions and procurement and distribution of essential drugs. There is importantly a need
for training and making available at the village level, skilled 'barefoot counsellors' who can be
supportive in generating solidarity at family and community level. This is an important gap
presently.
The welfare provisions of the 'People with Disability Act' need to be operationalized to benefit
the mentally ill persons and where needed additional welfare measures instituted. Mentally ill
persons cannot be well without the self-respect derived from being earning and contributing
members of the family and community. Livelihood generation supports are important, with
schemes addressing their special needs, where the ill person and the family are included.
There is need of educational campaigns to promote emotional wellness, at different walks of life.
One of the positive features of the HIV/AIDS prevention campaign is the belated recognition of
the importance of 'Life Skills Education' for adolescents. Other vulnerable segments also need
to be addressed through promotive programs, which also should include stigma reduction.
Community Level:
Mentally ill persons and their caregivers need to be consulted and included in the community
level developmental plans. Self help groups of only mentally ill persons are unlikely to be
practical (too few in a village). Self-Help Groups of disabled persons (including mentally ill
persons and caregivers) and which subsequently includes other marginalized group could be
the mechanism for inclusiveness. Such SHGs could play important role in fostering solidarity
and acceptance. At the same time awareness promotion through multiple means to address
community level stigma is needed. There is need of a mechanism to address speedily
exploitation and rights abuses, in the context of their vulnerability.
59
Family Support Structure:
Mentally ill persons in our experience get well within their family, as opposed to an institutional
care approach.
However the family needs new insights, skills and emotional support
themselves. This is to be made available through visits and counseling by volunteers and SHG
members who are trained themselves. Where family caregivers are not available, other local
support systems may be developed. Part of the getting well process, is recognition and
acceptance of their change by the family and community.
Individual level:
In the initial phase stabilization of the person's functioning and emotional state with appropriate
medications seem to be a cost-effective step. Several psychological needs of the individual
(such as need for structure, stimulation, belongingness etc.) require to get addressed. Beyond
that the affected individual makes the choice to get well and become a contributing member of
society.
Outcomes from Basic Needs India’s Partnership Experiences.
In the most recent review of Basic Needs India's work held with our primary partner
organizations, the major overall impact of our work was seen as the inclusion of mentally ill
people in family and community activities; their involvement in making decisions about
treatment and work opportunities; their increasing ability to access government poverty
alleviation's schemes; and their improved participation and visibility in social events.
The total number of mentally ill people identified by Basic Needs India in our projects in around
16000. About eighty percent of them have attended consultation, sixty percent of them are
under treatment and fifty three percent are engaged in productive work. Basic Needs India has
facilitated local policy initiatives of its partners, supporting them to root their advocacy actions in
research based evidence.
This has resulted in district official releasing free food quota to a family, the district mental health
teams extending clinics into the community, or the state mental hospital extending their services
to several district.
Key problems experienced in the work,
• District hospitals not equipped to provide treatment to mentally ill
• Non availability of psychiatric medicines through government centers (Taluk hospitals,
CHCs, PHCs etc.
• Mechanism for professional monitoring and follow up for side effects of drugs is inadequate,
and would require an enhanced team of paramedicals with simple training.
• Lack of awareness on mental health issues in the community, as well as resistance of the
community and the spouses of individuals in recognizing growth and change in individuals.
• People with minor mental illness not addressed at the community level.
• Gender related discrimination and oppression
• Harmful practices and human rights abuse existing in the community.
•
Problem of destitution (no care giver available)
•
Need for sensitive skills training (respecting the individual's dignity and gender sensitive) to
field staff of facilitating NGO and SHG group leaders.
Mani Kalliath- Basic Needs India
(Paper presented at International Health Forum for the Defense of People's Health on 15th Jan
2004, Mumbai)
60
Session 7
Prevention and promotional strategies: 60 minutes
1. Trainer invites participants to list out the causes of mental illness.
2. Trainer asks participants to reflect on the causes that can be prevented
3. Trainer asks participants to brainstorm on the promotional strategies for mental
health.
4. Trainer summarizes the discussion through power point presentation on the
promotional strategies, and share about preventions strategies for relapses.
5. Trainers shares with the participants on child mental health programme, and life
skill trainings, suicide prevention etc.
61
Session 7
Prevention of Mental Disorders
About 450 million people suffer from mental and behavioural disorders worldwide. One person
in four will develop one or more of these disorders during their lifetime. Neuropsychiatric
conditions account for 13% of the total Disability Adjusted Life Years (DALYs) lost due to all
diseases and injuries in the world and are estimated to increase to 15% by the year 2020. Five
of the ten leading causes of disability and premature death worldwide are psychiatric conditions.
Mental disorders represent not only an immense psychological, social and economic burden to
society, but also increase the risk of physical illnesses. Given the current limitations in
effectiveness of treatment modalities for decreasing disability due to mental and behavioural
disorders, the only sustainable method for reducing the burden caused by these disorders is
prevention.
Overall, the economic costs of mental ill-health are enormous and not readily measurable. In
addition to health and social service costs, lost employment, reduced productivity, the impact on
families and caregivers, the levels of crime and public safety and the negative impact of
premature mortality, there are other hard-to-measure costs, such as the negative impact of
stigma and discrimination or lost opportunity costs to individuals and families that have not been
taken into account.
To reduce the health, social and economic burdens of mental disorders it is essential that
countries and regions pay greater attention to prevention and promotion in mental health at the
level of policy formulation, legislation, decision-making and resource allocation within the overall
health care system.
Mental disorder prevention
Mental ill-health refers to mental health problems, symptoms and disorders, including mental
health strain and symptoms related to temporary or persistent distress. Preventive interventions
work by focusing on reducing risk factors and enhancing protective factors associated with
mental ill-health.
Although there are definitional nuances in the field, mental disorder prevention is broadly
understood Mental disorder prevention aims at “reducing incidence, prevalence, recurrence of
mental disorders, the time spent with symptoms, or the risk condition for a mental illness,
preventing or delaying recurrences and also decreasing the impact of illness in the affected
person, their families and the society”.
Mental disorders have multiple determinants; prevention needs to be a multipronged effort
Social, biological and neurological sciences have provided substantial insight into the role of risk
and protective factors in the developmental pathways to mental disorders and poor mental
health. Biological, psychological, social and societal risk and protective factors and their
interactions have been identified across the lifespan from as early as fetal life. Many of these
factors are malleable and therefore potential targets for prevention and promotion measures.
High co-morbidity among mental disorders and their interrelatedness with physical illnesses and
social problems stress the need for integrated public health policies, targeting clusters of related
problems, common determinants, early stages of multi problem trajectories and populations at
multiple risks.
62
Effective prevention can reduce the risk of mental disorders
There is a wide range of evidence-based preventive programmes and policies available for
implementation. These have been found to reduce risk factors, strengthen protective factors and
decrease psychiatric symptoms and disability and the onset of some mental disorders. They
also improve positive mental health, contribute to better physical health and generate social and
economic benefits. These multi-outcome interventions illustrate that prevention can be costeffective. Research is beginning to show significant long-term outcomes.
Prevention needs to be sensitive to culture and to resources available across countries
Current opportunities for prevention of mental disorders and mental health promotion are
unevenly distributed around the world. International initiatives are needed to reduce this gap
and to support low income countries in developing prevention knowledge, expertise, policies
and interventions that are responsive to their needs, culture, conditions and opportunities.
Effective prevention requires intersectoral linkages
Prevention of mental disorders and mental health promotion need to be an integral part of public
health and health promotion policies at local and national levels. Prevention and promotion in
mental health should be integrated within a public policy approach that encompasses horizontal
action through different public sectors, such as the environment, housing, social welfare,
employment, education, criminal justice and human rights. This will generate “win-win”
situations across sectors, including a wide range of health, social and economic benefits.
Protecting human rights is a major strategy to prevent mental disorders
Adverse conditions such as child abuse, violence, war, discrimination, poverty and lack of
access to education have a significant impact on the development of mental ill-health and the
onset of mental disorders. Actions and policies that improve the protection of basic human rights
represent a powerful preventive strategy for mental disorders.
Risk factors__________________________
• Academic failure and scholastic
demoralization
• Access to drugs and alcohol
• Caring
for chronically ill
or
dementia patients
• Child abuse and neglect
• Chronic insomnia and chronic pain
• Communication deviance
• Displacement
• Early pregnancies
• Emotional
immaturity
and
dyscontrol
• Excessive substance use
• Exposure to aggression, violence
and trauma
• Family
conflict
or
family
disorganization
• Isolation and alienation
• Lack of education,
transport,
housing
Medical illness
Neuro chemical imbalance
Parental mental illness
Peer rejection
Personal loss - bereavement
Poor nutrition
Poor social circumstances
Poor work skills and habits
Poverty
Racial injustice and discrimination
Reading disabilities
Sensory disabilities or organic
handicaps
Social incompetence
Stressful life events
Unemployment
Urbanisation
War
Work stress
63
Protective factors which has to be strengthened
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Ability to cope with stress
Ability to face adversity
Adaptability
Autonomy
Early cognitive stimulation
Empowerment
Ethnic minorities integration
Exercise
Feelings of mastery and control
Feelings of security
Good parenting
Literacy
Positive attachment and early
bonding
Positive interpersonal interactions
•
•
•
•
•
•
•
•
•
•
•
•
•
Positive parent-child interaction
Problem-solving skills
Pro-social behaviour
Self-esteem
Skills for life
Social and conflict management
skills
Social participation
Social responsibility and tolerance
Social services
Social support and community
networks
Social support of family and friends
Socio-emotional growth
Stress management
64
Session 7 b
What is Mental Health Promotion?
Mental health promotion often refers to positive mental health, considering mental health as a
resource, as a value on its own and as a basic human right essential to social and economic
development. Mental health promotion aims to impact on determinants of mental health so as to
increase positive mental health, to reduce inequalities, to build social capital, to create health
gain and to narrow the gap in health expectancy between countries and groups (Jakarta
Declaration for Health Promotion, WHO, 1997). Mental health promotion interventions vary in
scope and include strategies to promote the mental well-being of those who are not at risk,
those who are at increased risk, and those who are suffering or recovering from mental health
problems.
Defining mental health promotion
“Mental health promotion activities imply the creation of individual, social and environmental
conditions that enable optimal psychological and psycho-physiological development. Such
initiatives involve individuals in the process of achieving positive mental health, enhancing
quality of life and narrowing the gap in health expectancy between countries and groups. It is an
enabling process, done by, with and for the people. Prevention of mental disorders can be
considered one of the aims and outcomes of a broader mental health promotion strategy.”
Research shows that mental health promotion is a concept that has significant potential for
contributing to the well-being of individuals and communities.
Good mental health is a goal that most of us share, and mental health promotion is a means of
reaching that goal. Mental health is promoted through processes which give people the ability to
function well, or which remove barriers that may prevent people from having control over their
mental health.
For example, strengthening people’s ability to bounce back from adversity and manage the
inevitable obstacles that life tends to throw in our path is a fundamental way of promoting
mental health. In general, though, any actions which are taken for the purpose of fostering,
protecting and improving mental health can be seen as mental health promotion. These can
range from community-level interventions such as equitable social policy development, to
individual-level interventions which cultivate skills, attitudes and behaviors conducive to mental
health.
Mental health promotion applies to the whole population in the context of everyday life; it is not
only for those who experience mental health illness, nor for those who are considered to be at
risk. There is a role, however, for interventions designed specifically for certain groups, such as
people who care for a family member with mental illness.
There a few key factors to keep in mind in relation to mental health promotion. One is the
importance of informal relationships -- with friends, family, co-workers, and others - which play a
vital role in supporting and maintaining positive mental health. Mental health promotion
initiatives build on the networks of social support that are already present in communities, and
create new relationships that enhance our sense of belonging.
Secondly, it is important to consider that mental health promotion can take many forms.
Because positive mental health is the result of many interacting factors, there is no single way to
promote it. Communities are made up of a diverse range of people, so efforts to promote mental
health need to consider a variety of strategies and approaches that are relevant to the full
range.
65
Finally, it is essential that efforts to promote mental health recognize and reflect the diversity of
cultures within our communities; these efforts will contribute to building a society that ensures
fair and equitable treatment -- one that accommodates and respects the dignity of people of all
origins. To be successful, mental health promotion efforts require active citizen involvement in
identifying mental health needs, setting priorities, controlling and implementing solutions, and
evaluating progress towards goals - essentially a community development model.
Although the principles and processes may be similar, the outcomes of mental health promotion
and generic health promotion can be quite different whereas health promotion projects might be
working toward improved cardiovascular health or decreased rates of smoking, mental health
promotion focuses explicitly on mental health outcomes such as increased sense of personal
control, empowerment, self-determination, and resilience.
Much of the work of mental health promotion has to do with shifting attitudes -- emphasizing the
importance of maintaining positive mental health instead of dealing with individual distress, and
dealing with mental illness in a balanced and humane way that will dismantle stigma and
encourage recovery.
We all need mental health promotion. By identifying and activating the personal and social
strengths that support positive mental health, people can work together to develop healthier
communities.
There is no health without mental health: The essential dimension of mental health is clear from
the definition of health in the WHO constitution: "Health is a state of complete physical, mental
and social well-being and not merely the absence of disease or infirmity." Mental health is an
integral part of this definition. The goals and traditions of public health and health promotion can
be applied just as usefully in the field of mental health as they have been in the prevention of
infectious or of cardio-vascular diseases, for example.
Mental health is more than the absence of mental disorders: Mental health can be
conceptualized as a state of well-being in which the individual realizes his or her own abilities,
can cope with the normal stresses of life, can work productively and fruitfully, and is able to
make a contribution to his or her community. In this positive sense, mental health is the
foundation for well-being and effective functioning for an individual and for a community. This
core concept of mental health is consistent with its wide and varied interpretation across
cultures.
Mental health promotion covers a variety of strategies, all aimed at having a positive impact on
mental health. Like all health promotion, mental health promotion involves actions that create
living conditions and environments to support mental health and allow people to adopt and
maintain healthy lifestyles. This includes a range of actions that increase the chances of more
people experiencing better mental health.
Mental health is determined by socio-economic and environmental factors: Mental health and
mental health disorders are determined by multiple and interacting social, psychological, and
biological factors, just as health and illness in general. The clearest evidence is associated with
indicators of poverty, including low levels of education, and in some studies with poor housing
and poor income. Increasing and persisting socio-economic disadvantages for individuals and
for communities are recognized risks to mental health.
The greater vulnerability of disadvantaged people in each community to mental health disorders
may be explained by such factors as the experience of insecurity and hopelessness, rapid
social change, and the risks of violence and physical ill-health. A climate that respects and
66
protects basic civil, political, socio-economic and cultural rights is also fundamental to mental
health promotion. Without the security and freedom provided by these rights, it is very difficult to
maintain a high level of mental health.
Mental health is linked to behaviour: Mental, social, and behavioural health problems may
interact to intensify their effects on behaviour and well-being. Substance abuse, violence, and
abuse of women and children on the one hand, and health problems such as HIV/AIDS,
depression, and anxiety on the other, are more prevalent and more difficult to cope with in
conditions of high unemployment, low income, limited education, stressful work conditions,
gender discrimination, social exclusion, unhealthy lifestyle, and human rights violations.
Enhancing the value and visibility of mental health promotion: National mental health policies
should not be solely concerned with mental health disorders, but also recognize and address
the broader issues which promote mental health. These would include the socio-economic and
environmental factors, described above, as well as behaviour. This requires mainstreaming
mental health promotion into policies and programmes in government and business sectors
including education, labour, justice, transport, environment, housing, and welfare, as well as the
health sector. Particularly important are the decision-makers in governments at local and
national levels, whose actions affect mental health in ways that they may not realize.
•
Cost-effective interventions exist to promote mental health, even in poor populations
•
Low cost, high impact evidence-based interventions to promote mental health include:
•
Early childhood interventions (e.g. home visiting for pregnant women, pre-school
psycho-social interventions, combined nutritional and psycho-social interventions in
disadvantaged populations).
•
Support to children (e.g. skills building programmes, child and youth development
programmes)
•
Socio-economic empowerment of women
microcredit schemes)
•
Social support to old age populations (e.g. befriending initiatives, community and day
centres for the aged);
•
Programmes targeted at vulnerable groups, including minorities, indigenous people,
migrants and people affected by conflicts and disasters (e.g. psycho-social interventions
after disasters);
•
Mental health promotion activities in schools (e.g. programems supporting ecological
changes in schools, child-friendly schools)
•
Mental health interventions at work (e.g. stress prevention programmes)
•
Housing policies (e.g. housing improvement)
•
Violence prevention programmes (e.g. community policing initiatives); and
•
Community development programmes (e.g.
integrated rural development)
(e.g.
improving access to education,
'Communities That Care' initiatives,
67
Session 8
Child and adolescent mental health: 60 minutes:
1. Trainer introduces child and adolescent mental health problems through power
point/ chart presentation
2. Trainer divides participants in to three groups asks them to share their
experiences of seeing a child/ adolescent with emotional problems
3. Trainer invites groups to share their discussion in the larger group
4. Trainer summarizes the discussion sharing the various interventions.
68
Session 8
Mental health problems in children:
It's easy to know when your child has a fever. A child's mental health problem may be harder to
identify, but you can learn to recognize the symptoms. Like adults, children and adolescents can
have mental health disorders that interfere with the way they think, feel, and act. Untreated
emotional problems in children can lead to school failure, family conflicts, drug abuse, violence,
and even suicide. Untreated emotional problems in children can be very costly to families,
communities, and the health care system. Pay attention to excessive anger, fear, sadness or
anxiety. Sudden changes in your child's behavior can tip you off to a problem. So can behaviors
like exercising too much, or hurting or destroying things. The emotional disturbances in children
are differently presented when compared to that of adults. The communication of discomfort will
always be different in case of children when compared to that of adults.
Indeed, most parents are not abusive, but many are also unsupported and ill equipped for the
never ending demands of child care. Most parents wanted their children to secure good
percentage in exams in this competitive world. Their influences become stresses for the children
affecting their mental health. Others are poor, struggle with their own illness or substance abuse
problems or live in violent relationships. These are facts that are hard to reconcile.
Studies show that at least one in five children and adolescents have a mental health disorder. At
least one in 10, or about 6 million people, have a serious emotional disturbance
Be aware of adolescent experiences do not understand it has emotional problems:
•
•
•
•
•
•
•
•
•
•
•
•
•
Showing declining performance in school.
Losing interest in things once enjoyed.
Experiencing unexplained changes in sleeping or eating patterns.
Avoiding friends or family and wanting to be alone all the time.
Daydreaming too much and not completing tasks.
Feeling life is too hard to handle.
Hearing voices that cannot be explained.
Experiencing suicidal thoughts.
Poor concentration and is unable to think straight or make up his or her mind.
An inability to sit still or focus attention.
Worry about being harmed, hurting others, or doing something "bad".
A need to wash, clean things, or perform certain routines hundreds of times a day, in
order to avoid an unsubstantiated danger.
Racing thoughts that are almost too fast to follow.
Signs of Mental Health Disorders Can Signal a Need for Help:
Children and adolescents with mental health issues need to get help as soon as possible. A
variety of signs may point to mental health disorders or serious emotional disturbances in
children or adolescents. Pay attention if a child or adolescent you know has any of these
warning signs:
69
A child or adolescent is troubled by feeling:
Sad and hopeless for no reason, and these feelings do not go away.
Very angry most of the time and crying a lot or overreacting to things.
Worthless or guilty often.
Anxious or worried often.
Unable to get over a loss or death of someone important.
Extremely fearful or having unexplained fears.
Constantly concerned about physical problems or physical appearance.
Frightened that his or her mind either is controlled or is out of control.
The emotional disorders in children
Externalizing Disorders (ED): The term ED includes disorders with behavior that are disruptive
and aggressive, often harmful to others, some of the emotional disorders falling under this
category are:
Hyperactive attention deficit disorder (ADHD):
This disorder is identified by inattention, hyperactivity and impulsivity. The other disorders likely
to occur along with ADHD are depression, learning disorders, conduct disorders and anxiety
disorders.
ADHD produces two important conseguences in children - deficiencies in both academic and
social skills. In a school setting this problem is compounded by distraction and lack of
organization in school assignments. These difficulties result in lack of practice of basic skills
such as those gained by completing sets of arithmetic problems or spelling exercises.
Dyslexia:
Specific signs of dyslexia can be of three types - academic, motor and language
a. Academic - ask the child to write a few lines on any subject, check for spelling errors such as
reversal of letters or words that look like a mirror image of each other such as ‘no’ and ‘on’. The
child may make spelling mistakes by omitting letters or putting the wrong letters in a word. The
hand writing is often untidy. Difficulties in calculation can be tested by asking the child to repeat
multiplication tables. Dyslexia children have difficulty in putting the order of multiplication
correctly and get the results wrong.
b. Motor signs - the child may be restless or overactive. They may appear distracted and
forgetful. They may be clumsy. You can ask for right or left arm for right - left orientation. They
may be unable to do the shoe lace or button the shirt/ dress.
c. Language signs - There may be difficulty understanding instructions, reading a watch or
telling a story.
Conduct disorders (CD):
Children misbehave much more than are normal the important societal norms are violated and
the basic rights of others are often severely violated as well. The persistent behavior typical of
CD include aggressive actions that cause or threaten harm to people, or animals, non
aggressive conduct that causes property damage, major deceitfulness or theft and serious rule
violations. Several of these characteristic behaviors must have occurred in the past year and at
least one in the last six months.
70
The Internalizing Disorders (ID)
The ID refers to condition whose most important features is disordered mood or emotion. The ID
are often overlooked or at least not brought to clinical attention for long periods of time because they are less to detect and their potential seriousness is often discounted by parents
and teachers.
Separation anxiety disorder This is unique to children, they show excessive anxiety or even panic when they are not with
major attachment figures, usually parents or in familiar surroundings, although this is normally
common to childhood and decrease by the age of 10. These normally developmentally related
fears are different from the excessive reaction to separation that occurs in children who develop
a separation anxiety disorder.
Other Anxiety disorders:
These are not specific but occur also in adults. They are social phobia, generalized anxiety
disorder and obsessive - compulsive - disorder
Social phobia: Children show excessive shrinking from contact with unfamiliar people that
makes it hard for them to function normally in daily social contacts. However their relationships
with familiar people like family members are generally warm and satisfying.
Generalized anxiety disorder: Children must have been affected by anxiety symptoms for at
least six months to diagnose. This problem is related to situations that involve pressure for
performance or that carry the risk of loss of self esteem or feelings of lack of competence.
Obsessive - Compulsive Disorder: Obsession involves the persistent intrusion of intense,
unwanted, senseless thoughts while compulsions are marked by repetitive, ritualistic behaviors.
The younger the child is when severe symptoms develop, the more likely the disorder is to
continue into adulthood.
Depression: Although childhood is often pictured as a happy time of little responsibilities,
endless play and infinite enjoyments on the contrary depressive children/ adolescents show
withdrawal, volatile moods, problems with over eating and over sleeping and suicidal thoughts.
Failure to experience pleasure, apathy, low self esteem, fatigue, delinquent behavior, substance
abuse and poor school performance are some of the manifestations.
Bed wetting: Where children wet the bed at an age when they should not. The commonest
cause is a delay in this area of development of the child. Some children may start bed wetting
after having learned how to control their urine. This is often due to the child becoming upset
about something, such as fights in the family or arrival of a baby. Other less common reasons
include urinary infections, child abuse, diabetes, physical problems in the urinary tract and some
neurological problems.
71
Session 9
Mental health and development model: 60 minutes
1. Trainer divides participant in to three groups and ask them to list out the
2.
3.
4.
5.
needs of people with mental illness from their past experiences of knowing
the person with mental illness
Trainer invites the group to make presentation on the discussion
Trainer shares with them the needs expressed by people with mental
illness in past consultations through power point presentation/ chart
papers
Trainer summarizes the discussion through presenting Mental Health and
Development Model of Basic Needs
Trainer shares about BNI partnership and its activities
72
Session 9
Mental health and development model
Mental health and development is an innovative model. Basic Needs India believes that
how ever poor or ill the person is has the capacity to manage his or her life. Basic
Needs India believes that people with mental illnesses have rights and are entitled to
dignity and respect.
The vision and mission of Basic Needs India is:
• Basic Needs India seeks to satisfy the essential needs of all people with mental
illness in India and to ensure that their basic rights are respected and fulfilled
•
Initiate programmes in India which actively involve people with mental illness and
their carers and enable them to participate in their own development of larger
society. In so doing, stimulates supporting activities by other organizations and
influence public opinion.
Basic Needs India underlying conviction: “Mental Health is a Development Issue”.
Hence it aims at active participation of community in creating/designing a caring
accommodative and understanding environment to ensure fair treatment to PWMI in the
community. A holistic approach would include implementing existing policies and
advocating for the new ones.
Objectives of Basic Needs India is to:
• To restore mental health and human dignity, and ensure their rights
• To alleviate poverty through economically viable income generation activities,
• To carry out action research and disseminate the information and influencing
public opinion
• To work with government organizations / NGOs
Basic Needs India’s Approach
• “Inclusion of mentally ill in the development process”
• Work as collaborators with CBOs.NGOs and Government
• Consultations with PWMI to plan any programme
• Matching resources with needs
Basic Needs in participation with persons with mental illness, their carers\ families and
CBO’s evolved a model comprising of five modules. The mental health and
development model comprises five modules that are designed to make desirable
changes that facilitate social integration of people with mental illnesses adapting
development practices.
73
Community Mental Health
The purpose of Community Mental Health Care is to assist the individual with mental
illness to obtain an adequate level of functioning, to enable them participate in a
sustainable self-reliant programme leading them to exert the human potentials within
their own communities. The staff of the NGO’s will be trained in identifying persons
with mental health problems and designing a need based care programme and follow
up. Training will be provided by the staff of BNI and external resource persons and
organisations.
Capacity Building and Animation
As Basic Needs India works as a catalyst through NGO’s, it is important to build the
capacities of the local organisations so that they would be able to independently
manage the community mental health and development programme. The project
holders and the staff will be trained on an ongoing basis, the training will equip them
with the skills to manage all the capacity building elements of the programme.
In
particular the focus of this community development work will be mentally ill people
themselves and their carers affording them opportunities to come together at regular
intervals to talk about relevant issues and to assist them in developing appropriate
strategies in sustainable livelihoods. Capacity building will equip them with the
knowledge about the illness and the coping mechanism. Ultimately the stigma attached
to people with mental illness fades and they have a rightful place in their community.
Sustainable Livelihoods
Poverty is a consequence and cause of mental illness, therefore one of the touch
stone’s of the philosophy is to involve people with mental illness and family members in
economically viable activities. Using a group animation approach, mentally ill people will
be encouraged to find practical solutions to the problems that they themselves have
identified. Economic development programmes appropriate to the individual or his
family members will be designed. The CBO’s will also be trained in identifying local
resources and trades and in identifying the capabilities and making appropriate
referrals. Savings and credit groups comprising of mentally ill people and their carers
will be formed and appropriate links will be made to micro finance organisations and to
locally based schemes run by the Government for disadvantaged people.
Research
Action research will be developed along with people who have experience of mental
illness to understand their lives in the community. The NGO’s will document their
learning’s , experiences and impact and disseminate this information to other interested
organisations and individuals . The end product of research is attaining knowledge
leading to change in the life styles of people with mental illness as well as improving the
efficacy of mental health programs- of the partnership as well as of the government.
Administration
The programmes will be reviewed through meetings and field visits. Individual case
records and activities will be documented for monitoring and evaluation. Programme
and financial reports will also be submitted periodically.
74
Session 10
CBR and people with mental illness: 45 minutes
1. Trainer invites participants to share on the activities of the community based
rehabilitation
2. Trainer shares the community mental health and development activities
3. Trainer invites participant to identify similarities and differences in CBR and
community mental health and development work.
4. Trainer summarizes the discussion sharing their experiences of including
community mental health activities in their CBR programme.
75
Session 10
Community mental health services through CBR
Community based mental health services:
People and the community are the biggest resources available for the community mental health
services. Many of the mental health problems can be effectively dealt by the people and within
resources available close to them. Large-scale dissemination of knowledge and skills to people
would help in reducing stigma attached to illness. Building knowledge and awareness of families
can make the real difference. Should create a platform to discuss about “sound mind in sound
body” and importance of positive mental health and well being.
There is international focus of human resources for health care. The theme of the World Health
Report 2006(WHR 2006) is Working Together for Health.
The world health report 2006 emphasis that "the ultimate goal of health workforce strategies is
a delivery system that can guarantee universal access to health care and social protection to all
citizens in every country. There is no global blueprint that describes how to get there- each
nation must devise its own plan. Effective workforce strategies must be matched to a country's
unique situation and based on social consensus"(emphasis added)(p.119)
The 2001 WHO document, titled “Mental Health: New Understanding, New Hope” provide
importance to community based mental health services, emphasizing community acceptance,
family involvement, social integration and livelihood opportunities as a key components of the
interventions. This path- breaking WHO document proposed a new course of action for
implementing mental health programmes in developing countries. This course of action
promoted an approach where medical inputs were seen as a part of a larger whole, that
included income generation and mainstreaming individuals with mental health problems into the
full community.
Why mental health to be integrated in CBR programmes:
CBR programmes can and do successfully include people with mental illness and people with
psychosocial disabilities. This process has been beneficial to people with psychosocial
disabilities and their families, the CBR programmes themselves and the mental health services
for a number of reasons including:
•
Community processes, full participation, equal opportunities, social inclusion, gender,
diversity and a focus on rights are some of the key common elements of CBR work.
Community mental health work is no different so the programmes integrate well
together.
•
The high prevalence of psychosocial disabilities emerging through mental illness and its
impact on communities, societies and economies means that CBR workers are
confronted with the issues in their work. CBR programmes can have a positive impact on
the lives of people with mental illness, their families and on the situations in which
people live by including people with psychosocial disabilities in their programmes.
•
There are a limited number of mental health professionals and mental health services in
low income countries, making a CBR strategy which empowers community level
stakeholders to take action an important strategy.
76
•
The emerging trend away from vertical health programmes to integrated, multipurpose
health programme models favors primary level services and community-based
strategies.
•
There is an increasing recognition of the importance of early detection and treatment of
mental illness in order to prevent chronic conditions.
•
The goal of continuity of care and inclusion of people who are mentally ill into the
community is more readily achieved when there is an existing community-based
strategy.
•
The prevalence of mental health problems among people with other disabilities means
that a mental health component in the CBR programmes brings added value.
CBR approach and the role of the development workers
Development and changes in the concept of CBR over last two decades has influenced the
thought of inclusion of mental health in the CBR programmes. The CBR approach aims at
shifting rehabilitation interventions to homes and communities of people with disabilities, to be
carried out by the rehabilitation workers who are minimally qualified non professionals. The
main goal of rehabilitation has become broader than earlier, and focus beyond the individual, to
his community where he/she need to be integrated.
Thus the universal mission of CBR is:
1. To enhance activities of daily life of disabled persons (people with mental illness also
need help in this regard)
2. To create awareness in disabled person’s environment to achieve barrier free situations
around him and help him in meeting all human rights. ( need conducive environment,
where in people with mental illness are respected and their rights are protected, leading
to lead life in dignity)
3. To create a situation in which the community of the disabled persons, participates fully
and assimilated ownership of their integration in to the society. The relation ship here is
affected people ownership.
Advantages of integration of people with mental illness in the existing CBR programme would
be:
>
Meeting the needs of most disadvantaged group, been considered as disabled
as per the PWD act. Inclusion would ensure coverage of all people with
disabilities.
> This promotes faster integration of PWMI in to the mainstream societal activities.
> Promotes good mental health in the community and leads to early identification.
> Inclusion of PWMI in CBR programme would be cost effective.
> CBR strategies and approaches very much fit in meeting the needs of PWMI.
> Encourages innovative use of the resources like street theatre troops, advocacy
groups already existing.
> Mental health problems of people with disabilities also get addressed and add
value to the existing CBR programme.
> A conducive environment would be built where in all disadvantaged groups
including PWMI fully participate in their own development and the community in
which they live in.
Local community organizations staff like community rehabilitation workers/field staffs,
coordinators of self-help/user groups and other programmes, lay volunteers/ animators, nurses,
77
and health workers; who are not professionals in mental health or health care can provide
variety of services. Many of these informal community-care providers have little or no formal
mental health care training, but in many developing countries they are the main source of
community mental health provision. They are usually accessible and generally well accepted in
local communities. Mental health issues can be well integrated in to the community activities
and the other developmental activities of the development organizations.
Some of the important roles of the CBR /development work force are:
> Awareness raising and dissemination of information.
> Identification of people with mental health problems and referral to health services.
> Crisis support.
> Home based support - supportive care, including basic information and counselling.
> Helping in the activities of daily living skills and community reintegration.
> Integrating people with mental illness in to the self help groups (already existing)
> Formation of caregiver’s groups/associations.
> Supporting people with mental illness in accessing livelihood programmes and
government schemes
> Advocating the rights of PWMIs.
> Preventive and promotive services.
> Organising affected people to advocate for meeting their needs.
> Conducting consultation to understand the individual needs of person with mental illness
and to draw individual rehabilitation plan (IPR)
The interventions should be tailored to individuals’ needs and aimed to make the person
independent in community. Some may not have adequate skills to live independently in the
community. They might not have acquired the necessary skills or lost the skills due to the
illness. Then they need to learn/relearn the skills required to live in the community. Interventions
should be aimed at teaching these skills. Some may have frequent anger outbursts, which might
result in poor interpersonal relationships. Here focus should be on teaching the person on how
to control anger. Some may have multiple problems. It is necessary to prioritize which problem
should be tackled first.
The care for People with mental illness can be provided by :
> Family members providing care to PWMI starts from baring all the violent behaviour, to
accompanying them for treatment, than administering medicines, helping to engage in
gainful productive work.
> Community providing support for the well-being of PWMI. This is seen in the form of not
calling them as mad people, giving opportunities and advocating for the ensuring
measures to meet the needs of PWMI.
> Community based rehabilitation workers providing care for the PWMI and their families.
This starts with identification, assessment, follow up, home based support and linking
them to existing groups and mainstreaming.
> Organization providing support to deal with other associated problems of PWMI and their
caregivers. This is seen in the form of conducting camps, integrating them in to their
existing programmes.
> Provided with the above support, the role of mental health professionals would be more
meaningful.
A different and better world for PWMI can be created through community based mental health
services, where in the communities would understand issues related to mental health, resulting
in positive response to the issues. In this scenario the families of the mentally ill are vitally
involved in bringing change in the attitude of the community. Through these an environment of
mutual understanding can be built, where in PWMI enjoy their rights.
78
Session 11 :
Why community mental health: 60 minutes
1. Trainer invites participants to share their views on the prevalence of mental
illness (what is the percentage of people with severe mental illness, common
mental illness, epilepsy, mental retardation)
2. Trainer provides information on prevalence of mental illness, project numbers for Indian
population
3. Trainer asks the participants to share about the available mental health resources in the
country (number of mental hospitals, number of psychiatrist, psychologist, psychiatric
social workers, psychiatric nurses, budgetary allocations etc)
4. Trainer provides information on the available mental health infrastructure against the
projected numbers of prevalence of mental illness for the country
5. Trainer invites the participants to share about the attitudes of the community on people
with mental illness
6. Trainer shares their experience of working with people with mental illness and how the
quality of life has changed after the intervention
7. Trainer makes presentation on the district mental health programme (Bellary model to
11th five year plan)
8. Trainer invites participants to conclude the discussion by summarizing why community
mental health from the previous discussion
79
Session 11a
Why community mental health - some observations
Community Mental Health is concerned with the early recognition and treatment of the
mentally ill as close to their homes as possible, on an out -patient or day patient basis in
a centre situated in the middle of the community, with a short term in - patient treatment
facility leading to an early discharge and community -based rehabilitation.
•
One in four people suffer from a mental or neurological disorder at some point
during their life time. Prevalence of mental illness. 450 million people are
currently affected.
•
Major public health burden (30-40%,PHC) Association between physical and p
psychological problems
•
Able to transfer some of the mental health care skills to people so that care can
begin locally in their own locality (doctors, nurses, health workers, CBR workers)
•
Mental illness are very disabling
•
Depression is the number two public health problem in the world (121 million)
•
Inadequate mental health infrastructure in the country
•
Mental illness leads to stigma and isolation leading to marginalization becoming
vicious circle
•
Mental illness can be treated with simple, relatively in expensive
•
Small percentage require institutional care
•
Early diagnosis prevents unnecessary investigation and promotes recovery
•
Most disorders can be treated in the community and promotes early recovery
•
Most people with mental illness with adequate and appropriate care services will
be able to lead normal life and take care of their own life.
•
Un treated mental illness in the person leads to disability and increases the
burden of care for the family and for the state
•
When services are located locally it has more reach to meet the needs of vast
majority located in the community
•
People lock or chain their kith and kin (mentally ill) under pressure from others,
due to helplessness and ignorance of how to manage the person.
80
Session 11b
Community Mental Health: Need of the day
Mental health is as important as physical well-being of individuals, societies and
countries. Yet only a small minority of the 450 millions people suffering from a mental
or behavioral disorder are receiving treatment. Unfortunately, in most parts of the world,
mental health and mental disorders are not regarded with any thing like the same
importance as physical health. Instead they have been largely ignored or neglected.
Mental and behavioral disorders are estimated to account 12 % of the global burden of
disease, yet the mental health budgets of the majority of countries constitutes less than
1 % of their total health expenditure. World health organization actively propagating
community mental health for dismantling misconceptions/ discrimination, stigma and in
adequate services which is preventing many millions of people worldwide from receiving
treatment. Many countries have accepted WHO recommendation of inclusion of mental
health in the primary health care and establishing community psychiatry departments to
reach the un-reached in the community
The new innovations in modern pharmacological and behavioral medicines are creating
hope to the mentally ill and their families in all countries and in all societies. It extends
scope for prevention and the availability of treatment at the primary health care unit.
World health report provided following recommendation for all the developing countries
in order to improve mental health services in all developing and underdeveloped
countries.
The ten recommendations for action are as follows.
1. PROVIDE TREATMENT IN PRIMARY CARE
The management and treatment of mental disorders in primary health care is a
fundamental step, which enables poor mentally ill to get easier, and faster access to
services. There is also need to recognize that many people with common mental
disorders are already seeking help at this level. This not only gives better care; it is
economical as it cuts expenditure on creating a new system to treat people with mental
illness. It is also economical as it prevents unnecessary investigations and inappropriate
and non-specific treatments. For this to happen, however, general health personnel/
NGOs/community groups need to be trained in the essential skills of mental health care.
Such training ensures the best use of available knowledge for the largest number of
people and makes possible the immediate application of interventions. Mental health
should therefore be included in training curricula, with refresher courses to improve the
effectiveness of the management of mental disorders in general health services.
2. MAKE PSYCHOTROPIC DRUGS AVAILABLE
Essential psychotropic drugs should be provided and made constantly available at all
levels of health care. These medicines should be included in the essential drugs list,
and the drugs to treat conditions should be made available whenever possible. In some
countries, this may require enabling legislation changes. These drugs can ameliorate
symptoms, reduce disability, shorten the course of many disorders, and prevent
81
relapse. They often provide the first-line treatment especially in situations where
psychosocial interventions and highly skilled professionals are unavailable.
3. GIVE CARE IN THE COMMUNITY
Community care has a better effect than institutional treatment on the outcome and of
life of individuals with chronic mental disorders. Shifting patients from mental hospitals
to care in the community is also cost-effective and respects human rights. Mental health
services should therefore be provided in the community with the use of all available
resources. Community-based services can lead to early intervention and limit the stigma
of taking treatment. Large custodial mental hospitals should be replaced by community
care facilities, backed by general hospital psychiatric beds and home care support,
which meet all the needs of the ill that were the responsibility of those hospitals. This
shift towards community care requires health workers and rehabilitation services to be
available at community level, along with the provision of crisis support, protected
housing, and sheltered employment.
4. EDUCATE THE PUBLIC
Public education and awareness campaigns on mental health should be launched in all
Countries. The main goal is to reduce barriers to treatment and care by increasing
awareness on prevalence of mental disorders, their prognosis, treatment, the recovery
process and the human rights of people with mental disorders. The care choices
available and their benefits should be widely disseminated so that responses from the
general population, professionals, media, policy-makers and politicians reflect the best
available knowledge. This is already a priority for a number of countries, and national
and international organizations. Well-planned public awareness and education
campaigns can reduce stigma and discrimination, increase the use of mental health
services, and bring mental and physical health care closer to each other.
5. INVOLVE COMMUNITIES, FAMILIES AND CONSUMERS
Communities, families and consumers should be included in the development and de
cision-making of policies, programmes and services. This should lead to services being
better tailored to people’s needs and better used. In addition, interventions should take
account of age, sex, culture and social conditions, so as to meet the needs of people
with mental disorders and their families.
6. ESTABLISH NATIONAL POLICIES, PROGRAMMES AND LEGISLATION
Mental health policy, programmes and legislation are necessary steps for significant
and sustained action. These should be based on current knowledge and human rights.
The health department needs to increase their budgets for mental health programmes
from existing low levels. Some states have recently developed or revised their policy
and legislation has made progress in implementing their mental health care
programmes. Mental health reforms should be part of the larger health system reforms.
Health insurance schemes should not discriminate against persons with mental
disorders, in order to give wider access to treatment and to reduce burdens of care.
7. DEVELOP HUMAN RESOURCES
Most states need to increase and improve training of mental health professionals, who
will provide specialized care as well as support the primary health care programmes.
Most developing countries lack an adequate number of such specialists to staff mental
82
health services. Once trained, these professionals should be encouraged to remain in
their native states and in positions that make the best use of their skills. This human
resource development is especially necessary for countries with few resources at
present. Though primary care provides the most useful setting for initial care, specialists
are needed to provide a wider range of services. Specialist mental health care teams
ideally should include medical and non-medical professionals, such as psychiatrists,
clinical psychologists, psychiatric nurses, psychiatric social workers and occupational
therapists, who can work together towards the total care and integration of patients in
the community.
8. LINK WITH OTHER SECTORS
Sectors other than health, such as education, labor, welfare, and law, and
nongovernmental organizations should be involved in improving the mental health of
communities. Nongovernmental organizations should be much more proactive, with
better-defined roles, and should be encouraged to give greater support to local
initiatives.
9. MONITOR COMMUNITY MENTAL HEALTH
The mental health of communities should be monitored by including mental health
indicators in health information and reporting systems. The indices should include both
the numbers of individuals with mental disorders and the quality of their care, as well as
some more general measures of the mental health of communities. Such monitoring
helps to determine trends and to detect mental health changes resulting from external
events, such as disasters. Monitoring is necessary to assess the effectiveness of mental
health prevention and treatment programmes, and it also strengthens arguments for the
provision of more resources. New indicators for the mental health of communities are
necessary.
10.
SUPPORT MORE RESEARCH
More research into biological and psychosocial aspects of mental health is needed in
order to increase the understanding of mental disorders and to develop more effective
interventions. Such research should be carried out on a wide international basis to
understand variations across communities and to learn more about factors that
influence the cause, course and outcome of mental disorders. Building research
capacity in developing countries is an urgent need.
Mental and physical healths are the two vital strands of life that are closely interwoven
and deeply interdependent. Advances in behavioral medicines have shown that like
many physical illnesses, mental and behavioral disorders are the result of a complex
interaction between biological, psychological and social factors. Community care is
about providing good care and the empowerment of people with mental and behavioral
disorders. In practice community care implies the development of wide range of
services with in local settings.
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Session 11c
Mental Health in India - An Overview
1. Introduction
Mental, behavioral and social health problems are an increasing part of health problems
in the world and in India too. Though the burden of illness resulting from psychiatric and
behavioral disorders is enormous; it is grossly under represented by conventional public
health statistics, which lead to focus on mortality rather than morbidity and on being
dysfunctional. The number of people with mental illness will increase substantially in the
coming decades. It is seen that there is an increase in the number of young adults with
mental disorders, and 50-75% of mental disorders begin during youth. Secondly, there
has been substantial increase in the geriatric population having mental health problems,
as the life expectancy is increasing. Thirdly, social factors which are established risk
factors are also causing a change in the rate of depression seen in all age groups.
Mental and behavioral disorders account for 12% of the global burden of disease. It is
estimated that nearly 450 million people suffer from a mental or behavioral disorders in
the world. Nearly 10 % of disability adjusted life years (DALYs) across all age groups
are due to depressive disorders, suicides and alcohol related problems. Depression
ranks third among men and second among women, yet mental health budgets of most
of the countries are less than 1% of the total health expenditure. Mental disorders also
kill in many indirect ways such as suicides, worsening the outcome of physical illness,
medical complications and injuries related to alcohol abuse (i.e mental disorders as a
risk factor for other health problems),unhealthy lifestyles and so on.
2. Ground realities
2.1 Demographic Characteristics
India is a country with an approximate area of 3287 thousand square kilometres (UNO,
2001). Its population is over one billion and the sex ratio (men per hundred women) is
106 (UNO 2004). The literacy rate is 68.4 % for men and 45.4% for women. The
proportion of population under the age of 15 years is 32 % and the proportion of
population above the age of 60 years is 8%. The life expectancy at birth is 60.1 years
for males and 62 years for females. The healthy life expectancy at birth is 53 years for
males and 54 years for females.
2.1 Prevalence
A majority of the classical psychiatric epidemiological studies in the last four decades
have been population based, focusing on general psychiatric morbidity in a small to
medium population. From these house-to-house surveys, it is found that:
•
•
An estimated 1 percent of the population, including children suffering from severe
mental disorders.
Five to ten percent of the population is reported to have common mental
disorders.
84
15-20 % (in some studies it is 40 %) of the people approaching primary health
care centers, general hospitals or private clinics for general health problems
requires psychiatric assessment and evaluation. Some of them are not aware of
it. They think and believe that they have some physical illness, and take various
methods of treatment for relief, often in vain. Some of them are not aware they
suffer from a biomedical mental illness, but they are aware that their symptoms
are related to stress. In most other cases, the morbidity is unrecognized by
doctors who treat the condition with symptomatic drugs .
If this figure is projected in India, there would be more than ten million people suffering
from severe mental illness, and the figures for common mental disorders would be five
to ten times that of severe mental illness. In addition there are issues related to suicide,
substance abuse and mental disorders in children. There is also a close association of
mental illness with the larger social development agenda, such as the Millenium
Development Goals (MDGs).
2.3 Mental Health Care
Mental health care has always been influenced and determined by contemporary
beliefs, and India is no different. Traditionally, mentally ill people were often cared in
temples and religious institutions, based on the principles that mental illness is a form of
spiritual affliction and could thus be cured by religion. Superstition with inadequate
mental health services in the community makes subjects people with mental illness to
various harmful treatments. Often, certain treatment practices by black-magicians,
village quacks, witches and physical abuse in the name of treatment can have harmful
effects on the people with mental illness. They are kept outside the margin of the
community by being chained, locked in rooms, found wandering on the streets, or
staying for ever in closed wards of asylums, hospitals, etc. While the situation described
above is mostly applicable only for the rarer, severe forms of mental disorder (e.g.
psychotic disorders) the vast majority of mental disorders are either managed at home
or through primary care
2.4 Stigma and Discrimination
A large section of people with mental illness are still locked inside their houses without
any treatment, because their family members don’t recognize the illness or they find it
embarrassing to be recognized as family member of a mentally ill person, who are
commonly called as ‘mad’. There is also a fear that they would be victims of disgrace
and indignity and thereby lose the status or acceptance they enjoy in the community.
The stigma is so tremendous that people feel ashamed and deny the illness. Therefore,
the first and foremost element that shrouds the realm of mental illness is stigma
attached to it. The very thought of some one in the family getting mental illness is a big
shock and they do not want to believe it.
Due to stigma attached to the families, people with mental illness become the victims of
discrimination and human rights abuse. The discrimination is seen from the family
members and goes right up to the policy makers and state authorities. The attitude of
the public is often, "who cares about what is done for people with mental illness”.
85
People with mental illness have been treated as second-class citizens with no adequate
facilities given, either at the state or the central government. As a result they face
chronic ill health, and are seen as an economic and social burden to the community,
leading to social destitution. Soon families lose hope and are left to the mercy of others.
2.5 Human Rights Violations
People lock or chain their kith and kin under pressure from others, due to helplessness
and ignorance. It happens due to the ignorance of family members and community in
which they live. It happens in hospitals, asylums and special homes. It is grossly
inhuman. Violence against women is a public health concern in all countries and
especially women with mental illness are often subjected to physical and sexual abuse.
2.6 Existing Laws
As per the law, a person with mental illness cannot sign any documents of sale,
purchase, lease or any contract. The act is silent on these issues during the lucid
moments or stabilized stage. Family members, mostly brothers, take undue advantage
of this clause to deny property rights to the person with mental illness and enjoy all the
property.
Marriage and Divorce Act also permits legal separation of life partners if one of them is
found to be mentally ill (certified by a psychiatrist). Generally in rural communities men
are permitted to marry for the second time if his first wife is suffering from any disease
like mental illness, epilepsy and so on. On the other hand if a married man becomes
mentally ill, the community insists that the wife continues to be the caregiver. If a family
has a person with mental illness, getting life partner for a boy or girl from that family is
almost next to impossible because of the stigma, as it is seen as a family illness. There
are occasions where they hide the information and problems erupt after the marriage. It
is also common that a close relative gets pressurized to marry such a person. Stigma
also affects health care insurance - many companies exclude mental illness from their
cover.
2.7 Social Determinants
Poor people with mental illness are not only vulnerable due to their condition, but also
the vulnerability brought about by poverty, which is related to their condition. One of the
main reasons that people find it hard to accept people with mental illness as equal
members of their communities is that they do not see them as capable of contributing to
the household or the community. The effects of social determinants such as poverty,
conflict, gender disadvantage, social exclusion, etc. on mental illnesses are well known.
It is also found that, people are not able to access care due to their social conditions.
And due to inadequate treatment, people with mental disorders remain disabled for
longer and incur greater health care costs and lesser ability to work, thus worsening
poverty.
86
3. Infrastructure and Present Status
The major changes in mental health scenario began with the tragedy at Erwadi, the
asylum fire in the Ramanathapuram district of Tamil Nadu. It was a disaster that opened
the eyes of policy makers and the general public to attend to the needs and voices of
people with mental illness. During the last 50 years, the place of mental health as part
of the general health has changed to some extent. From a situation of no organized
mental health care at the time of independence, currently mental health issues are seen
as part of the public agenda in a few places at least and part of the credit goes to the
intervention of the judiciary.
While mental health has been stated as part of primary health care system on paper,
primary health centers (PHCs) are not equipped to treat people with mental illnesses in
their centers. Only few primary health centers (where programmes such as the District
Mental Health Programme or DMHP are implemented) provide mental health care and
treatment in the community. In addition, PHCs are not geared towards the provision of
chronic disease care (which is a characteristic of most mental disorders), and
psychosocial interventions are rarely available in any sector.
3.1 Treatment Facilities
Most of the district hospitals are not fully equipped and supplied with psychiatric
medicines to treat people with mental illness; most often they are referred to multi
specialty centers in the capital cities or big towns. Many medical professionals view
mental health as an alien subject and do not give importance to either learn or practice
it in their day-to-day practice.
There are 42 mental hospitals in the country with the bed availability of 20,893 in the
government sector and another 5096 in the private sector hospital settings to take care
of an estimated 1,02,70,165 people with severe mental illness and 5,12,51,625 people
with common mental disorders needing immediate attention.
Psychiatric medicines have been supplied only in a few primary health centers,
community centers and district hospitals. Amitriptyline, lithium, chlorpromazine (CPZ),
phenobarbital, phenytoin sodium, haloperidol, carbamazepine, imipramine and
risperidone are made available in a few district hospital. The rates of risperidone (better
drug than CPZ in terms of side effects) are cheaper then CPZ. Unfortunately, drugs like
CPZ which have lesser utility have been purchased in surplus, (for example in
Karnataka). Adequate laboratories facilities are also lacking in the district hospitals to
find out the serum level for lithium administration. None of these drugs are routinely
distributed by government to the primary health centers except in some districts, where
DMHP is operational. Services like child guidance and rehabilitative services are also
available only in mental hospitals and in big cities.
One third of the mental health beds are in the state of Maharastra and several states do
not have mental hospitals. Some mental hospitals have more than 1000 beds and
several still have a large proportion of long stay patients. During the past two decades,
87
many hospitals have been reformed through the intervention of the voluntary
organizations, media, National Human Rights Commission (NHRC) and the judiciary.
Availability of psychiatric beds in India
Total psychiatric beds per 10,000 population____________
Psychiatric beds in mental hospitals per 10,000 population
Psychiatric beds in general hospitals per 10,000 population
Psychiatric beds in other settings per 10,000 population
0.25
0.2
0.05
0.01
The survey of 37 mental hospitals conducted between November 2001 and January
2002 revealed a dismal picture. Apart from poor infrastructure, the greatest deficiencies
were in the area of qualified staff. Some mental hospitals do not have even a single
psychiatrist on their permanent roster.
Survey results of mental health facilities in India
SI.
No.
J_
2_
3_
4
5
6
7
8
Facilities
Adequate
Number
%
Infrastructure_______________________ 12
32.4
Staff______________________________ 10______ 27
Clinical services including investigations 16_______ 43.2
Availability of medicines and treatment 28
75.7
modalities________________ ________
Quality of food______________________ 23
62.2
Availability of clothing and linen_______ 15
40.5
Recreational facilities________________ 18
48.6
Vocational rehabilitation facilities
14
37.8
Inadequate
Number
%
25_____
67.6
27_____
73
21_____
56.8
9
24.3
14
22
19
23
37.8
59.5
51.4
62.2
3.2 Mental Health professionals
We have limited facilities to train human resource in mental health. The irony is that
inspite of this, all centers have become centers to export trained mental health
professionals abroad. Many mental health professionals are immigrating to other
developed countries, where jobs are more lucrative. For instance in 2003 itself, more
than 82 psychiatrist sought short term and long term employment in the United Kingdom
in response to the latter’s international recruitment drive.
Undergraduate training in psychiatry is not changing in spite of many efforts and this
continues to be a major barrier to create medical doctors adequately trained in
psychiatry after their basic training. Some of the government and private medical
colleges do not have the departments of psychiatry in its full strengths to train young
medical graduates in psychiatry,
The inadequacy of mental health human resource is a major barrier in caring for people
with mental illness in the community. Even most of districts don’t have public sector
psychiatrists. Comparatively mental health professionals are more in the states of
Kerala and Tamil Nadu. Very few mental health professionals are based in rural areas.
Many states allow public sector psychiatrist to have private clinics.
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Availability of mental health professionals in India
Number of psychiatrist per 100, 000 population______
Number of psychiatric nurses per 100,000 population
Number of psychologist per 100,000 population
0.2
0.05
0.03
3.3 General Hospital Psychiatry
It is speculated that the birth of general hospital psychiatry in India was due to lack of
sufficient funds to open more mental hospitals. These new units needed mobilization of
very few resources like a little space in an already functioning hospital and few mental
health professionals to manage the people with mental illnesses. What probably started
as an economic necessity, has now become a major force in the delivery of health care.
A provision for establishment of inpatients wards for people with mental illnesses
requiring admission has been provided in the Mental Health Act. It has to be noted that
the psychiatric units in the general hospitals are not well established, and are not able
able to take care of psychiatric problems associated with other illnesses.
3.4 Private Psychiatry
It is interesting to note that very large numbers of private psychiatrist have located
themselves in cities that are district headquarters but are not the state capitals. The
reason could be that most state capitals have medical college departments of psychiatry
or some other governmental psychiatric facility and a private psychiatric facility would be
more welcomed in other cities of the state where no such facility exists. It seems that
distribution of private psychiatrists in India is in a way related to the position of the
states in socioeconomic hierarchy. Thus relatively prosperous states with higher
number of literate people (like Kerala and Tamil Nadu) have the highest number of
psychiatrists. North zone has proportionately lesser number with the exception of
Punjab and Delhi. States of the Central and East zone have the least number of
psychiatrists in private practice.
3.5 Mental Health Financing
The country spends 2.05% of the total health budget on mental health. The primary
sources of mental health financing in descending order are tax based, out of pocket
expenditure by the patient or family, private insurance and social insurance.
Government fund for health services are provided both by the states and the center. In
the tenth five-year plan estimates, mental health constituted 2.05% of the total plan
outlay for health. The country has a Disability Act, which has included mental illness as
the seventh disability. However in reality, people with mental illness rarely avail any
benefits available under disability schemes.
3.6 Regional Disparity
The state run health care system in India is striving hard to overcome the regional
disparity between rural and urban. The adequate health services and the normal health
89
standards in rural areas seem to be much below the average. Cities and big towns are
growing with private health care facilities catering to the needs of middle class and rich
communities. The costs for diagnosis and treatment are so exorbitant that some get into
debt traps. In rural areas hardly any facilities exist and the attitude of the government
health professionals are often not patient friendly. The budgetary allocation for mental
health is very meager, as most of it goes to maintenance of hospitals and a very little
portion for treatment.
3.7 Non-Governmental Organisations (NGOs)
NGOs are involved with mental health in the country mainly in the areas of advocacy,
promotion, prevention, treatment and rehabilitation. They are also involved in
counseling, suicide prevention, training of lay counselors, and provision of rehabilitation
programmes through day care, sheltered workshops, halfway homes, hostels for
recovering patients and long term facilities. There are also self-help groups of parents
and people with mental illness that have been recently established. It has to be noted
that most of the NGOs have their setups and outlets in the urban areas catering to the
needs of middleclass and higher economic groups.
It is evident from the above reading that mental health care in India is characterized by:
Very limited mental health care facilities;
(i)
Grossly inadequate professionals to provide mental health care;
(")
(iii)
Less than 10% of those needing urgent care are getting any modern medical
care;
(iv)
Families are the current care providers but with limited support and skills for
care
No support schemes for voluntary organization;
(v)
Lack of a regular mechanism for public mental health education;
(vi)
Limited administrative structure for monitoring the mental health programme
(vii)
and
(viii) Limited budget for mental health care as part of the total budget
4. Policy and legislation
4.1 National Mental Health Programme (NMHP) 1982
The National Mental Health Program is the outcome of the developments in providing
mental health care through different methods as well as the overall goals of the health
care in general. The first concerted efforts to formulate a national program were held in
July 1981. Later, on August 2 1982, a small group of experts met to consider the
revised document and finalize the same. This document was presented to the central
council of health and family welfare and the committee recommended the NMHP for
implementation.
90
The objectives of the program are:
> To ensure availability and accessibility of minimum mental health care for all in
the foreseeable future, particularly to the most vulnerable and underprivileged of
the population
> To encourage application of mental health knowledge in general health care and
social development.
> To promote community participation in mental health services development and
to stimulate effort towards self -help in the community.
The specific approaches suggested for the implementation of the NMHP are:
>
>
>
>
>
Diffusion of mental health skills to the periphery of the health service system
Appropriate appointment of tasks in mental health care
Equitable and balanced territorial distribution of resources
Integration of basic mental health care with general health services
Linkage to community
o
4.1.1 Progress of the NMHP
From the time of the formulation of the NMHP in August 1982, in the last two decades
the following initiatives and activities have been taken up in districts where the district
mental health programme has been implemented:
> Sensitization and involvement of state level programme officers
> Workshops for voluntary agencies
> Workshops for mental health professionals namely psychologists, psychiatric
social workers and psychiatric nurses
> Training programmes in public mental health for programme managers
> State level workshops for the health directorate personnel, development of
models of integration of mental health into primary health up to the district level
> Preparation of support materials in the form of manuals, health records for
different types of health personnel and health education materials
> Training program for teachers of undergraduate psychiatry
> Initiation of district mental health programme in 28 districts of 22 states
> Expansion of the district mental health programme for 100 districts with the
budgetary allocation of rupees 190 crores in the 10th five-year plan (2002-03 to
2006-07).
4.2 The District Mental Health Programme (DMHP)
The DMHP, which operates as part of the National Mental Health Programme was
launched in 1996-97 in four districts. By 2000 the DMHP was extended to 22 districts in
20 States and Union Territories and by 2002 the DMHP further extended to 27 districts
in 22 States and Union Territories, providing for services to over 40 million of the
population. In the current 10th plan period the government has announced the
programmes extension to 100 districts across the states, with a total budget outlay of
200 crore rupees
There have been many barriers to reach the goals set out in the 1982 document. The
goals were too ambitious to begin with and sufficient attention was not paid to all
91
aspects of implementation of NMHP. The other important barrier has been the lack of
funding. Though NMHP came up in 1982 the subsequent three five years plans did not
make adequate funding allocation. Further even the funds allotted were not fully utilized.
It was only in the 9th Five-year plan that a substantial amount of Rs 28 cores was made
available and it was projected to be Rs 190 cores in the 10th Five-year plan.
The critical review of District Mental health programme reveals that:
•
•
•
There was lack of administrative clarity to utilize the allocated funds. The
programme looked good on paper, but was extremely unrealistic in its targets,
especially considering the available resources of manpower and funds for its
implementation.
The approach was top down and did not take into consideration the ground
realities. The poor functioning of the primary health care in India in general as well
as the poor morale of the health workers not taken into account. A structure that
was attending to given tasks so inadequately would certainly be unable to absorb
new targets of integration.
The DMHP continues to be the extension of professionals rather than integration of
mental health with primary care
Central Government has sanctioned DMHP in 100 districts in the year 2004. The
districts are yet to implement the programme and to appoint required mental health
professionals for the programmes. It has to be noted that a few districts do not have
psychiatrists and the facilities in the district hospital to support the mobile team of the
district mental health programme.
4.3 National Health Policy- 2002
The 2002 National Health Policy (NHP 2002) refers twice to mental health. In its
assessment of the current scenario, Section 2.13 states that: 'Mental health disorders
are actually much more prevalent than is apparent on the surface. While such disorders
do not contribute significantly to mortality, they have a serious bearing on the quality of
life of the affected persons and their families. Sometimes, based on religious faith,
mental disorders are treated as spiritual affliction. This has led to the establishment of
unlicensed mental institutions as an adjunct to religious institutions where reliance is
placed on faith cure. Serious conditions of mental disorder require hospitalisation and
treatment under trained supervision. Mental health institutions are woefully deficient in
physical infrastructure and trained manpower. NHP 2002 will address itself to these
deficiencies in the public health sectoh.
Section 4.13 states the policy prescription towards mental health: ‘NHP 2002 envisages
a network of decentralized mental health services for ameliorating the more common
categories of disorders. The programme outline for such a disease would involve the
diagnosis of common disorders, and the prescription of common therapeutic drugs, by
general duty medical staff.
The proposed National Mental Health Policy outlines the prioritized agenda for
extending within a pragmatic time frame basic mental health care facilities to all sections
of the populations across the country by the year 2020.
92
4.4 Legislations Related to Mental Health:
The Mental Health Act of 1987 and the Persons with Disabilities Act 1995 are the two
legislations that are directly applicable to people with mental illness. While these are
legislations, the World Mental Health Atlas 2005, reports that there is no Mental Health
Policy in India.
4.4.1 The Mental Health Act (MHA), 1987
Mental Health Act is “an act to consolidate and amend the law relating to the treatment
and care of mentally ill persons, to make better provision with respect to their properly
and affairs and for matters connected therewith or incidental thereto". In the Mental
Health Act, 1987, a modest attempt has also been made to bring mental illnesses on
par with physical illnesses, thus reducing the stigma attached to mental illnesses
The Mental Health Act is not just a cosmetic improvement over the out dated Indian
Lunacy Act 1912, but represents the conclusion of lengthy presentation by the Indian
Psychiatric Society to the Government of India. This Act came into force in April 1993,
as per the Government of India order, even though it is still in hibernation in some
states. The establishment of mental health authorities, both at the center and state is a
welcome step. These authorities are expected to act as a friend, philosopher and guide
to the mental health services. Provisions have been made for establishing separate
hospitals for children under the age of 16 years; for people abusing alcohol and other
drugs and for other special groups. Emphasis on outpatient care has been made to
safeguard the human rights of the mentally ill person. Stringent punishment has also
been prescribed for those who subject the mentally ill to physical and mental indignity
within hospitals.
The notion of care in the community has not been addressed in the current legislation.
No effort has been made to provide after care services for the discharged patients.
There is no thinking over the alternative to hospital care. Authorities are using the
clauses of the act leading to many medico-legal problems, and difficulties for the private
nursing homes.
The Ground Realities of its Implementation: The Mental Health Act has not been
implemented in Arunchal Pradesh, Chhattisgarh, Uttaranchal, Bihar, and Orrisa. State
Mental health Authority has not been constituted in Arunchal Pradesh, Chhattisgarh,
Uttaranchal, Bihar and Orrisa. Mental health rules have been framed only in Goa,
Manipur, Sikkim, Assam, Chandigarh, Delhi, Gujarat, Madya Pradesh, Mizoram, and
Tamil Nadu.
4.4.2 The Persons with Disabilities (Equal Opportunities, Protection of Rights and
Full Participation) Act 1995
The Persons with Disabilities (Equal Opportunities, Protection of Rights and Full
Participation) Act 1995, commonly called the PWD act came into force on February 7,
1996. This law is an important landmark and is a significant step in the direction of
93
ensuring equal opportunities for people with disabilities and their full participation in the
nation building. The Act provides for both preventive and promotional aspects of
rehabilitation like education, employment and vocational training, job reservation,
research and manpower development, creation of barrier-free environment,
rehabilitation of persons with disability, unemployment allowance for the disabled,
special insurance scheme for the disabled employees and establishment of homes for
persons with severe disability etc. There are also statutory bodies for implementing the
Act at central and state levels.
Even though it is encouraging that mental illness has been considered in the act, the
later chapters of the act do not talk about any provisions to be given or set aside for
people with mental illness. The act also does not assure the right to treatment. While
there is much talk about the implementation or lack of implementation of the Act, there
is little understanding about the indicators to measure the level of implementation. At
present, conducting a session on the Act or putting up posters on the Act, are referred
to as ‘advocacy’. A clearly defined set of indicators for the implementation needs to be
worked out. There is also a great need to come up with strategies to decentralize the
implementation of the Act at the district/ taluk and village level.
5. Conclusion
The rate of mental illness is being increasingly recognised across different divides like
the rich and the poor, urban and rural and so on. With some help from the judiciary, it
seems like the states are taking notice of the gravity of the issue and attempting to
address the needs of people with mental illness.
Health including mental health is a fundamental right. Millions in India perhaps, don’t
know that it is their right to avail treatment. People with mental illness are crying l,My
name is today” Do we hear their voice?
REFERENCES
Mental Health- An Indian Perspective (1946-2003) By S.P. Agarwal
4- Mental Health In India (1950-2000), Essays In Honour of Professor N.N WIG,
Edited By R. Srinivasa Murthy.
4 Mental Health Atlas 2005, World health organization (WHO)
4 Quality Assurance in Mental Health, By National Human Rights Commission
(NHRC)
4 The World Health Report 2001, Mental Health: New Understanding, New Hope
4 World Health Organization (2001b) Atlas: Mental Health Resources in the world
2001,WHO, Geneva
4 World Health Organization (2004a) The world health Report 2004: Changing
history, WHO, Geneva
4 World Health organization (2004b) Atlas: Country Resources for Neurological
Disorders 2004, WHO Geneva
94
Chapter 4
The trainees should be able to:
1. Understand what is capacity building in the context of determinant)
2. Understand barriers in the family and community for the recovery of person with
mental illness.
3. Understand role of Gender in illness presentation and recovery
4. Design appropriate awareness programme to deal with the barriers in the family
and community.
5. Understand the strategies for inclusion of people with mental illness in the
community groups and in accessing community resources).
Number of sessions : 8
Session 1: Capacity Building
Session 2: Animation
Session 3: Understanding barriers - Family and community
Session 4: Organizing people with mental illness and caregivers in to self help
groups/associations
Session 5: Care givers needs
Session 6: Awareness generation
Session 7: Awareness materials
Session 8: Gender and mental health
95
Session 1:
Capacity building : 30 minutes
I. Trainer asks the participants to share their views on what is capacity building in
the context of determinants
2. Trainer writes the responses in the black board
3. Trainer defines capacity building
4. Trainer invites comments from the participants to share on different levels of
capacity building for different groups
5. Trainer invites list of people whom the capacity to be build on mental health
issues in the community.
6. Trainer invites participant to summarize on the need for community groups
trainings/ awareness for various groups in the community.
Session 1
CAPACITY BUILDING
o
Capacity Building is:
•
Engaging minds and hearts with whom we work
•
It means being sensitive, actively listening and dialoguing
•
Understanding from stakeholders, and their perspectives
•
Preserving human dignity even in the context of struggle
•
Dealing with diversity
•
Active engagement as a means to an end
•
Thirst for search
Promoting critical thinking
Using materials which touch our emotions that propels us to action
Dropping baggage or our own biased beliefs about self and people
Nothing happens until we reduce strategy to work
Peter Drucker
96
Session 2:
Animation: 60 minutes
1. Trainer plays a DVD on the Tom and Jerry for 10 minutes
2. Trainer invites participants to share their view on the cartoon seen
3. Trainer divides participants in to 3 groups and ask them t discuss on what is
animation
4. Trainer invites group to make presentation on their discussion
5. Trainer sums up the discussion by sharing principles of animation
6. Trainer invites comments on difference between facilitation and animation
7. Trainer writes down the responses on the black board.
8. Trainer makes a presentation on difference between facilitation and animation.
97
Session 2
Animation
In Greek, the word anima means life, soul, and auto-movement. In the context of
community development, animation means the group getting life and the
group/community getting stimulated so that it moves, lives and develops. Once
stimulated the people would undertake initiatives based on their awareness and
knowledge. They assess the reality in which they live and gain confidence to mobilize
them selves and the larger community to seek the change they want. Therefore,
animation is process oriented. The process starts from where people are and certainly
not where you want them to be. The time and space available is best utilized by the
group to undertake self-analysis of their situation, causes, facts, etc., that form the basis
for initiating change. From there follows the plans, strategies, mobilizing required
resources, demanding their rights, executing their plans, reviewing the outcomes, etc.
Thus they become the primary stakeholders in their own development.
Animation is that stimulus to the mental, physical, and emotional life of people in a given
area which moves them to undertake a wider range of experiences through which they
find a higher degree of self-realization, self-express, and awareness of belonging o a
community which they can influence (Simpson 1989:54)
Therefore, the dynamic process of animation:
• Promotes critical thinking & self-enquiry
• Promotes social change
• Promotes self-help
• Increases capacities of the group/community
• Ensures community taking control of its own development
As Paulo Freire has said, the issues facing people are often complex and no expert has
all the answers. On the other hand, nobody is totally ignorant. Each person has different
perceptions based on their own experience. To discover valid solutions, everyone
needs to be both a learner and a teacher. It is a mutual learning process. This
understanding is a must for good animator. Animator should have genuine belief that
people, however poor or ill are they; have the capacity to contribute to the
transformation of their community. Animation is not a mere technique; it is a belief
animator lives through. S/he genuinely takes guard not to control the group but to
enable the group grow in awareness, maturity and self-reliance. It calls for intense faith
in human beings; their power to make and remake, to create and recreate; faith that the
vocation to be fully human is the birthright of all people, not the privilege of an elite. The
animator should be fully conversant with the needs of the group. They include:
• Acceptance
• Sharing information and concerns
• Setting goals
• Organising for Action
Acceptance
The uniqueness of each person, with her/his own experience and insights, needs to be
recognized. The acceptance of each member should be such that s/he feels safe to say
98
in the group what s/he really thinks and feels. Hence building such atmosphere is of
vital importance for any group to move forward.
Sharing information and concerns
People working in groups need information about each other; their experience, their
ideas, their values and opinions and about the issues which they consider to be
important in their lives. They need to workout for them selves.
Very often the concern of the animator and those who arranged the meeting will be to
help deepen their awareness, to move from the symptoms to the causes of the problem.
The best way is to pose the problem.
Setting goals
Unless the goals are set clearly by the group, people will not be interested or committed
to carrying them out. Unless the goals are clear to all, people become frustrated. The
way decisions are made is directly related to how committed people feel to carrying
them out.
Organizing for action:
To achieve the goals set, definite people need to take specific responsibility and should
be accountable to the group. Actions get started and the group feels the ownership.
Ten Principles for an Animator
1. Approach each situation with humility and respect
2. Understand the potential of local knowledge
3. Adhere to democratic practice
4. Acknowledge diverse ways of knowing
5. Maintain a sustainability vision
6. Put reality before theory
7. Embrace uncertainty
8. Recognize the relativity of time and efficiency
9. Take a holistic approach
10. Exercise an option for community
Things to remember:
An animator is an applied sociologist. S/he should/must:
• Know some important features of the subject.
• Always be able to separate what is happening to the overall community itself, in
contrast to what is happening to particular individuals.
• Encourages the community to choose what it wants so as to be more consistent
with prevailing values and attitudes - does not impose her/his notion.
• Be able to identify the leadership within the group.
• Know the local structures and functions
• Be aware of what the prevailing beliefs are in the community.
• Learn more and more about their culture, and the dynamics of the culture
dimensions.
• Be aware that each person brings unique skills and knowledge to a process.
• Put reality before theory - real issues and complexity of community, which must
be the starting point for learning and transformation.
99
Session 3:
Understanding barriers - Family and community: 120 minutes
1. Trainer invites participants to share their experiences of home visit of person with
2.
3.
4.
5.
6.
7.
8.
mental illness in their families.
Trainer notes down the supportive environment and barriers from their sharing.
Trainer divides participants in to three groups, assigns topics for discussion
Group one discusses the attitude of families towards family members with
mental illness
Group two discusses the attitude of communities towards people with mental
illness
Group three discusses the attitude of local government/local leaders towards
meeting the needs of people with mental illness.
Trainer invites group to make presentation on their discussion.
Trainer invites participant to summarize the presentation.
100
Session 3
Understanding barriers in the family
3
101
U5»
Session 4:
Organizing people with mental
groups/associations: 60 minutes
illness
and
caregivers
in
to
self
help
1. Trainer invites participants to share their views on inclusion of people with mental
illness in the community activities
2. Trainer notes down the responses on the black board
3. Trainer shares the experiences of including people with mental illness in the
disability groups
4. Trainer invites participants to share their views on difference between impairment
and disability, by asking them to respond on the statement “all visually impaired
people are not disabled”.
5. Trainer invites participant to summarize the discussion on impairment and
disability
6. Trainer invites participants to share their views on mental illness and disability.
7. Trainer summarizes the discussion on mental illness and disabilities
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Session 4
Caregiver’s forum
Caregiver’s forum consists of old and new members (caregivers and stabilized
individuals) in a given locality, who meet regularly to share experiences. The sharing of
experiences and convictions from old members benefits the new. It is a forum where
people (caregivers) gain new insights and make attitudinal changes and gain courage to
take action to solve their problems. For women carers, it is often an opportunity to come
out of the (isolating) home atmosphere and gain confidence in-group situations. Often
they gain confidence in speaking in a group, which can be an achievement in itself.
Information’s about medicines, side effects, effective ways of administering (in noncooperative clients), and other related information’s are learned from experienced
carers. Over a period of time attitudinal changes takes place in individual cares in areas
such as:
- about trying out hospital medicines and sticking through the early difficulties with
medicines
- about seeking government benefits
- about volunteering to help other affected families in simple ways
- about taking responsibility for the affected ward (there are examples of ‘shifting
responsibility’ towards affected individual by giving in marriage a PWMI, resulting in
compounding of the problem).
The members learn to take responsibility for self help actions (an early one being
holding the caregivers meetings regularly). Leadership and initiatives are fostered.
Some groups decide to act on local community issues thereby contributing to the larger
community leadership (eg getting municipality/ panchayat authorities to attend to civic
amenities)
The active members in the forum get identified over a period of time and get selected to
be representatives in the larger apex body (federation).
They would be enabled
representatives of PWMI.
through
building
capacity
to
function
as
effective
103
Session 5: Caregivers needs: 30 minutes
1. Trainer invites participants to list out the needs of caregivers of people
with mental illness.
2. Trainer invites some caregivers members to the session and share their
experience of being caregiver (video clipping)
3. Trainer shares with the group of the caregivers meetings held and its
benefits.
4. Trainer summarizes the discussion sharing about care givers
associations, how federations have included mental health issues in their
activities, and alliance building.
104
Session 6
CARERS, THEIR ROLE IN HEALING
Severe mental disorder is the most common and disabling mental disorder, affecting
nearly 1% of the population world wide. The illness is characterized by delusional and
confused thinking, hallucinations and social isolation. In fact, more than 40 percent of
people with severe mental disorders have problem in participating in the structured
activity on a daily basis. Constantly care should be provided for motivating people with
mental illness to lead life with dignity.
Family members can play an important role in helping the person with severe mental
illness. Before they can be properly supportive, however, they must first understand and
accept that mental illness is a disorder of the brain just like diabetes is a disorder of the
body; not anyone's fault; and not an indication of moral or spiritual failure. Family
members need to know this so that they do not blame their mentally ill relatives, or think
of them as lazy. People with mental illness are often incapacitated, and a drain on
family energy and resources, but this is not intentional on the part of them, who are in
many ways victims more than anything else
The most important thing family members can do to support their ill relatives is to help
them remain oriented and on task with their routines; helping them stay on medications,
and attend scheduled and doctor visits, for instance. Family members can help their
mentally ill relative by helping them with personal care, eating a well-balanced diet, and
getting regular exercise. Caring for mentally ill relatives is frequently painful and
heartbreaking. Family members some times need support and platform for ventilation
for themselves. Participating in a self-help group for families of psychiatric patients is
known to reduce family member's sense of burden, aloneness and stress, provides
support and encouragement to continue their caring.
Especially for poor persons with mental illness, it leads to extreme marginalization of the
individual and the family, as both these hampers the ability to be productively engaged,
and to access necessary resources for that. PWMI’s initiative is affected by internal
factors (within the individual) and external factors (due to lack of specific support
facilities). The social stigma further blocks community support and access to resources.
Poverty and Gender compound these dynamics. Being mentally ill and a female, the
family’s investment for care is likely to be less and so also other support needed for
recovery. Consequences are unhappy lives of individuals sometimes leading to extreme
crisis, poor coping abilities of the family, lost productivity and stress in the community.
Because of the paucity of mental health care, families have been given more
responsibilities to care their mentally ill family member, whether it was by choice or our
cultural influence or due to the lack of facilities, it is difficult to conclude, though there is
some evidence to support that family involvement in care was and continues to be a
preference of families. It is unfortunate that the experiences of the families have not
been adequately studied and the strengths not been optimally utilized in the recovery of
people with mental illness.
105
A Good caregiver is one who has
1.
2.
3.
4.
5.
6.
7.
Time for the mentally ill family member
Person who lives close by to mentally ill person
The person should have patience.
Has good emotional relationship
Has positive attitude towards the person,
Believes that all problems can be solved, be positive
The person is motivated to care and also has capacity to motivate the person
with illness.
8. Creates favorable atmosphere for the person to be rehabilitated at home.
The basic level of care required for person with mental illness is
1. Follow up care/ need to give medication/ supervise whether the person is taking
medicines
2. Need to provide adequate amount of nutritious food
3. Need to encourage the person for socialization
4. Need to motivate and monitor person for maintaining personal hygiene
5. Need to motivate the person for taking small responsibilities
6. Create awareness among the community so that the person with mental illness is
accepted and integrated in all community activities
7. Engage in income generation/ productive activities.
In taking care of the people with mental illness, the carers play an important and
difficult role, especially when their wards have severe mental illness. Their role is
not as much recognized as the medicines and the doctor. This was evident in the
findings of the annual reviews of Basic Needs, India. The carer(s) has/have a
responsibility which is quite heavy and may weigh against their health and mental
health as well.
106
Session 6:
Awareness generation: 60 minutes
1. Trainer divides the participants in to 4 groups.
2. Trainer assigns each group a role play to be performed on awareness generation
on mental health issues for based on their understanding of determinants
a. ICDS/Anganwadi teachers
b. Volunteers/ panchyath members
c. Community members
d. Women’s group
3. Trainer invites groups to perform role plays
4. Trainer invites comments from the participants after the completion of role play
from each group
5. Trainer discusses with the group on areas that need to be improved while they
create awareness on mental health issues
Session 6
Awareness generation
During the community meeting the field staff would share with the group
1.
2.
3.
4.
5.
6.
7.
Misconceptions/attitudes of people related to people with mental illness.
What is mental health
Features of mental illness
Causes of mental illness
Need for inclusion in the community activities and in the self help groups.
Importance of continuing treatment.
Treatment facilities available in their locality.
107
Session 7:
Awareness materials: 60 minutes
1. Trainer asks the participants to go back to same groups and design a poster/
awareness material depicting the messages for the awareness programme.
2. Trainer distributes, sketch pens, old magazines, and chart paper
3. Trainer allows group to discuss on the posters to be developed
4. Trainer invites group to share their posters, followed by discussion on the
posters.
5. Trainer summarizes the discussion.
Session 7
Awareness materials
A list of the awareness materials developed and maintained by our partners
1. Posters
2. Wall writings
3. Street theater scripts
4. Pluck cards
5. Banners
6. Handbook
7. Booklet on the legislations and the provisions
8. Pamphlets/hand bills
9. Videos
10. Audio cassettes
11. Presentations
12. Flip charts
13. Life stories and case studies
14. Resource directories
15. Calendars
108
Sample Posters on Mental health
POSTER -1
A person with good mental health
•
•
•
•
Has clarity in his/her mid, is able to cope with his/her emotions and feelings and
is able to carry out daily work and lead a normal life.
Has strength to face his regular problems, pin and disappointment.
Is able to live in harmony with and to relate to people around him.
Is able to keep his balance through the normal ups and downs in his life.
A mentally ill person
•
•
•
Might speak and behave differently from the normal way.
Might have strange and dangerous thoughts.
Might continuously find it difficult to do his/ her work and / or relate to others.
Causes of mental illness: Primary cause is unknown. But the following could cause
mental imbalance and illness.
• Chemical change in the brain, caused by virus infection, tumor or blood clotting.
• Severe injury to the head to the nervous system.
• If there is a history of mental illness in the family.
• Excessive consumption of alcohol or drugs for a long period of time.
• A sudden shock due to an unexpected or massive loss or tragedy.
• Very bitter experience in childhood and deeply disturbed family atmosphere.
• Social problems such as unemployment, extreme poverty and deprivation.
• Being subjected to serious and constant cruelty, violence and abuse.
Who can be affected by mental illness?
Men, women, Children, Literate, illiterate, poor or rich, those living in villages or citiesanyone can be affected by mental illness
109
POSTER-2
Symptoms of mental illness
•
•
•
•
•
•
•
•
•
Abnormal speech, behaviour or expression of feelings
Disorder in sleep, hunger and sexual desire.
Disinterest in self-care (looking after oneself)
Baseless fears, anxiety and anger.
Sleeplessness, lack of appetite or interest in self-care.
Desire to be left alone and or/ wandering aimlessly
Dependency and disinterest in normal social life.
Confused mind and sometimes, loss of memory.
Reduced ability to take appropriate and timely decisions.
Symptoms of common mental disorder
• Long term depression, feeling excessively nervous, anxious or scared.
• Lock of clarity in thinking or dealing with ordinary, everyday situations
• Unusual behaviours, which may be embarrassing but is harmless.
The person is aware of the reality and that he has a disorder
Symptoms of severe mental disorder
•
•
•
•
•
•
•
•
Dangerous behaviour, being extremely quarrelsome or withdrawn
Abnormal behaviour (Example. Laughing without reason, talking irrelevantly or
talking to oneself)
Being excessively suspicious, having very wrong beliefs and wild imagination.
These persons may hear or see things that others cannot and may, therefore, be
confused due to that
Two contradictory kinds of behaviours in the same person such as depression at
times and highly excited at other times.
Serious depression and thoughts of suicide.
Lack of memory, lack of concentration, irregular in activities.
Usually, these persons are not aware that they are ill.
110
POSTER-3
Can mental illness be cured?
Yes, it can be...
• If it is identified at an early stage and treated
• By taking treatment and medicines regularly.
Following are not correct or proper methods to cure a person with mental illness.
> Witchcraft
> Marriage
> Scaring, branding or chaining up the person
POSTER -4
Person with mental illness needs persons who love and understand them.
They too have human rights like us.
What can you do?
• Increase their self-confidence by giving them affection, encouragement and
support.
• Include them in the festivals you celebrate.
• Guide and encourage mentally ill persons to go to primary health centers or a
hospital to get treatment.
• Help them to get some vocational training
• Create an opportunity for them to work and give them job according to their
capacity.
• Recognise and respect their rights. Help them get the benefits from
government schemes.
• Ensure that the mentally ill participants in the discussions concerning them
and meat for their benefits.
Ill
Session 8:
Gender and Mental health : 90 minutes
2. Trainer introduces the gender concept inviting participants to share their
experiences of the games they played while they were in their childhoods and
adolescence.
3. Trainer ask group to reflect on the changes occurred from their childhoods to
adolescence regarding gender relationship
4. Trainer divides participants in to four groups and ask group to discuss:
(condensed case study of Gullappa, lakshmana, sugunamma, sasarasamma)
The causes of the illness if any
ii.
The impact of illness on the person
iii.
Support network
5. Trainer invites groups to share their discussion in the larger group
6. Trainer ask group to identify the differences in the case studies
7. Trainer summarizes the discussion
112
Session 8
Gender and mental health
113
Chapter 5
Livelihoods and income enhancement
The trainees should be able to:
1. Understand relationship between mental illness and poverty
2. Understand family as a unit
3. Understand about the trade analysis
4. Understand various livelihood options
Why do you think we all need livelihood and income enhancement?
Trainer notes: independent living, self worth, how ever the world operates on
interdependence.
Do you think in your opinion people with mental illness are different from this?.
Number of sessions: 5
Session 1: Poverty and mental health
Session 2: Poverty: Cause and consequences of mental illness
Session 3: Sustainable Livelihoods
Session 4: Livelihood intervention
Session 5: Trade analysis
114
Session 1
Poverty and mental health
Prosperity: 20 minutes
1. Trainer invites participants to share their thoughts on poverty.
2. Trainer list out the responses in the black board.
3. Trainer asks participants look in to their own responses and reflect on is it
problem based or intervention based.
4. Trainer introduces the concept of prosperity!.
5. Trainer shares his views on poverty eradication and prosperity.
Trainer notes:
a. Deprivation of capabilities (access to assets, access to knowledge and skills is
real poverty)
Self worth: 20 minutes
1. Trainer invites participants to form 3 groups, and share their thoughts on one’s
self worth.
2. Trainer notes down the responses from the presentations
3. The trainer introduces a paper on Looking at Self-Worth(SLB, Handout-2) to the
participants. He suggests the participants to take a few minutes to look at the
same and fill the appropriate columns with a minimum choice of five under each.
4. On completion, the trainer invites the participants to share their view on the
picture that emerges about them selves.
Trainer notes: from the time we have come to this world, we wanted to be
loved/accepted/appreciated/respected/understanding by all, and we work towards being
loved similarly people with mental illness would have self worth and they need to be
loved/understood/ respected/opportunities to be listened to, participation to the extent.
Leading to recovery: 20 minutes
1.
2.
3.
4.
5.
Trainer invites the participants to share their views on recovery.
Trainer writes the responses in the black board.
Trainer summarizes the indicators of stabilization.
Trainer makes presentation on the definition of recovery.
Trainer discuss with the participants on need for reasonable accommodation.
Trainer notes: opportunities in socialization and any livelihood activities would faster the
recovery process. Being aware of the nature of illness providing reasonable
accommodation in organized and unorganized sectors is essential.
115
Session 1
Human Dignity
Dignity is a term used in moral, ethical, and political discussions to signify that as a living being
has an innate right to respect and ethical treatment. Individuals have inherent, inviolable rights,
and this is closely related to concepts like virtue, respect, self respect, autonomy, human rights,
and enlightened reason. Dignity is generally proscriptive and cautionary: it is usually
synonymous to 'human dignity', and is used to critique the treatment of oppressed and
vulnerable groups and peoples, though in some case has been extended to apply to cultures
and sub-cultures, religious beliefs and ideals, animals used for food or research, and even
plants.
In more colloquial settings it is used to suggest that someone is not receiving a proper degree of
respect, or even that they are failing to treat themselves with proper self-respect.
The Universal Declaration of Human Rights, adopted by the United Nations General Assembly
on December 10, 1948, states:
Article 1. All human beings are born free and equal in dignity and rights. They are endowed
with reason and conscience and should act towards one another in a spirit of brotherhood.
Article 2. Everyone is entitled to all the rights and freedoms set forth in this Declaration, without
distinction of any kind, such as race, colour, sex, language, religion, political or other opinion,
national or social origin, property, birth or other status. Furthermore, no distinction shall be
made on the basis of the political, jurisdictional or international status of the country or territory
to which a person belongs, whether it be independent, trust, non-self-governing or under any
other limitation of sovereignty
Human dignity is a type of worth that every human being has. It is used as a right of respect
during political, moral, or ethical conversations. When someone is humiliated, it is damaging
their human dignity.
Human dignity is an expression that can be used as a moral concept or as a legal term.
Sometimes it means no more than that human beings should not be treated as objects. Beyond
this, it is meant to convey an idea of absolute and inherent worth that does not need to be
acquired and cannot be lost or sold. Human dignity is inviolable, it should be respected and
protected.
The dignity of the human person is not only a fundamental right in itself but constitutes the real
basis of fundamental rights. The 1948 Universal Declaration of Human Rights enshrined this
principle in its preamble: ‘Whereas recognition of the inherent dignity and of the equal and
inalienable rights of all members of the human family is the foundation of freedom, justice and
peace in the world’.
116
Session 1 b
Self-Worth
Identity is a person’s sense of placement in the world -- that which tethers us to our self
worth. Our identity can easily be over-inflated when our self-worth is miscalculated. Real
self-worth is entirely internal. It’s realizing the true strengths of the individual. How you
feel about yourself is self-esteem. It is your perception of how you are doing in the
world. Self-esteem may go up or down depending upon what is happening to you. Get
an "A" on a test and you feel great, but if you fail you feel terrible. Self-esteem is
changeable. Self-worth differs from self-esteem. Self-worth is what you are born with.
As one of the creations of the universe you are worthwhile and have value, which
cannot be taken from you.
Self-worth is frequently based on our feelings of worth in terms of our skills,
achievements, status, financial resources, and physical attributes. This kind of self
worth often cultivates an independent attitude. When we find ourselves not measuring
up to society’s criteria for worth, we suffer serious consequences and our self-worth
depreciates dramatically. Self-worth decreases faster with the feeling of regret, anger,
and fear.
Every individual experiences basic needs -- hunger, thirst, fatigue, etc. We are
conditioned to satisfy these needs by getting something -- food, drink, or rest.
Mistakenly we conclude that by getting, we will achieve an acceptable selfworth/esteem. Self worth is related to self-esteem is an attitude of respect for and
contentment with oneself based on the recognition of one’s abilities and acceptance of
one’s limitations.
117
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118
Session 1 c
Prosperity
Prosperity is the state of flourishing, thriving, success, or good fortune. Prosperity often
encompasses wealth but also includes others factors which are independent of wealth
to varying degrees, such as happiness and health.
Economic notions of prosperity often compete or interact negatively with health,
happiness, or spiritual notions of prosperity. For example, longer hours of work might
result in an increase in certain measures of economic prosperity, but at the expense of
driving people away from their preferences like family life, and health. In Buddhism,
prosperity is viewed with an emphasis on collectivism and spirituality. This perspective
can be at odds with capitalistic notions of prosperity, due to their association with greed.
Data from social surveys show that an increase in income does not result in a lasting
increase in happiness; one proposed explanation to this is due to hedonic adaptation
and social comparison and a failure to anticipate these factors, resulting in people not
allocating enough energy to non-financial goals such as family life and health.
Economic growth is often seen as essential for economic prosperity, and indeed is one
of the factors that is used as a measure of prosperity. Many distinct notions of
prosperity, such as economic prosperity, health, and happiness, are correlated or even
have causal effects on each other. Economic prosperity and health are well-established
to have a positive correlation, but the extent to which health has a causal effect on
economic prosperity is unclear. There is evidence that happiness is a cause of good
health, both directly through influencing behavior and the immune system, and indirectly
through social relationships, work, and other factors.
The assumption that economic prosperity requires growth seems so reasonable that
most of us don’t think much about it. The trouble is, the word "growth" has two
fundamentally different meanings: "expansion" and "development." Expansion means
getting bigger; development means getting better, which may or may not involve expansion.
119
Session 1 d
Recovery
Recovery is a process, a way of life, an attitude, and a way of approaching the day’s
challenges. The need is to meet the challenge of the illness/disability and to re
establish a new and valued sense of integrity and purpose within and beyond the limits
of the illness/disability; the aspiration is to live, work and love in a community in which
one makes a significant contribution.
Person in the recovering phase will be:
a. Free from the symptoms/problems because of the illness.
b. Ability to understand the importance of care services and value same
(follow the instructions).
c. Able to take care of his personal hygiene.
d. Able to involve in productive work in the family.
e. Contributing towards family income through involving in livelihood
activities.
f. Participating in the self help group meetings and the activities.
g. The person has taken control of making the decision in his or her life
h. The person has come to an understanding and acceptance of his or her
life experiences
i. The person is taking proactive steps in promoting his or her own wellness
What recovery does not mean
1.
2.
3.
4.
5.
Recovery does not mean a person will no longer experience symptoms
Recovery does not mean a person will no longer have struggles
Recovery does not mean a person will not use medication
Recovery does not mean a person will no longer utilize mental health services
Recovery does not necessarily mean a person will be completely independent in
meeting all of his/her needs.
120
Session 2
Poverty: Cause and consequences of mental illness: 60 minutes
1. Trainer divides participants in two three groups.
2. Trainer distributes news print on farmer’s suicide, women poisoning children and
committing suicide, and suicides because of family problems.
3. Trainer asks the group to identify issues in the news prints.
4. Trainer invites groups to make presentation on their discussion.
5. Trainer invites one of the participants to summarize all the three presentation,
ask them to link poverty and mental health.
6. Trainer invites participants to share case histories/stories of few families having
mentally ill members, describing access to care services since the onset.
7. Trainer list out the (black board) cost involved in caring a mentally ill person from
the narrative of the case histories of the participants.
8. Trainer summarizes on consequences of mental illness.
Trainer notes:
Some of the hidden cost are cost for travel, meeting the expenses like black magician,
temple etc. The burden of care givers are social burden, economic burden,
psychological and emotional burden. Mental illness is a family diseases, family to be
seen as a unit rather than individual mentally ill person.
121
Session 2a
Sustainable Livelihoods
A sustainable livelihood approach should operate at two fundamental levels.
One level works directly to provide poor people with better access to assets or ways of
improving existing assets. The second level works at a macro level, influencing policies
in the private and public sector and promoting more effective functioning of structures
and processes, thereby ensuring that livelihood strategies are open to poor people in a
sustainable and equitable manner.
Basic Needs seeks to work at both levels in its work with people with mental illness.
The Sustainable Livelihoods Programme
Sustainable Livelihoods and the mentally ill
The issues of choice, access and opportunity are key issues that concern us when
working with people with mental illness. For people with mental illness, who also find
themselves in a position of long term poverty, the need for access and opportunity to
sustainable livelihoods, as defined by Chambers and Conway “capabilities, assets
including both material and social resources, and activities required for a means of
living” is critical not only to tackling poverty but also providing a means of rehabilitation
and regaining confidence and a place in the community. “A livelihood is sustainable
when it can cope with and recover from stresses and shocks and maintain or enhance
its capabilities and assets...” (Chambers and Conway 1999). When dealing with poor
people with mental illness, we have to consider not only their vulnerability due to their
condition, but also the vulnerability brought about by poverty, which is a consequence
and to some extent cause of their condition. It is this cycle, which mental health and
development programme aims to address through its sustainable livelihoods
interventions.
POVERTY
MENTAL ILLNESS
(increased due to continued pressures
of poverty, inability to access
resources for medical care
rehabilitation)
MENTAL ILLNESS
(often caused by or
exacerbated by condition
of poverty)
/h POVERTY
(due to inability to work,
poor access to reliable medical
assistance, cost of drugs/treatments)
122
This is the reality of the debt trap in the specific context of the family unit affected by
mental illness.
“One of the main reasons that people find it hard to accept mentally ill people as
equal members of their communities is that they do not see them as capable of
contributing to the household or the community. In poor rural communities the
‘value’ attached to an ability to earn income is great and often is the defining factor
for a person’s standing within the family”. “Mental illness causes severe stigma for
the whole family and carers are also severely neglected due to their association with
a mentally ill person. Bringing financial stability to the family unit and providing a
productive role for mentally ill people is critical so that they are able to take care of
their basic needs for food, nutrition, health, and education”.
Caregivers continue to express during our consultation process a desire to address the
financial burden caused by the cost of caring for the mentally ill person. There is a real
need to increase the family’s income in order to cope with the additional stresses
created by the search for a ‘cure’, the need for regular medicines and the loss of a
former or potential income source. In turn, mentally ill people themselves express the
wish to get back to work or take up new income generating opportunities, both as a
means of activity and also to alleviate the stress on their families. Since it may not be
possible for a person to return to a former employment, though that must be a key
objective, there is a need to explore other suitable options, taking into account individual
skills and capabilities as well as local opportunities and markets. Support is required to
ensure the long-term sustainability of a particular work placement or trade, not only in
material/financial terms but also in the context of the person’s illness.
The importance of the model outlined above is that it demonstrates how a poor person
can spiral downwards through mental illness and presumably by interaction with mental
health specialists can also spiral upwards. If we take this further, we could imagine the
following cycle:
POVERTY
(Poverty lessened)
MENTAL ILLNESS
(recognized/ stabilized)
MENTAL ILLNESS
(improved through
medical care and
rehabilitation)
POVERTY
(Stabilized)
Sustainable Livelihoods: A definition
Introduction
123
The concept of sustainable livelihoods is inextricably linked with an understanding of
poverty in its broadest sense - not only access to material and economic assets but
also to basic human rights, dignity, autonomy and social inclusion in a sustainable
manner.
Singh and Gilman (1999) define sustainable livelihoods as those, “derived from people’s
capacity to exercise choice, access opportunities and resources, and use them in ways
which do not foreclose options for others making their living, either now or in the future.”
The meaningful work model:
The importance of the meaningful work model is that it demonstrates the concept of
stabilisation leading to a reintroduction to choice for the mentally ill person. In our
experience, many have demonstrated on the ground a willingness, indeed eagerness,
to exercise that choice and return to a form of employment. However, it is necessary to
recognise that this choice is circumscribed by constraints of poverty that, equally, exist
for ‘normal’ people in poverty. As a consequence of this, it is imperative that we work
within the community to extend, in a sustainable way, the range of choice available and
to deepen the ability of the options available to address poverty.
The whole thrust of the work therefore is to:
(a) return mentally ill people to a range of options that exist in the community
(b) where possible collaborate with organisations/structures that are seeking to extend
the range of those options (or to get mentally ill people recognised as potential
participants within existing options).
Employment
Micro enterprise development
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124
Programme Focus
The primary unit of Basic Needs India sustainable livelihood intervention is the family of
the mentally ill person seen as a whole unit. The intention of the intervention is to
enable the mentally ill person and their family to improve the family’s assets in a way
that directly incorporates the mentally ill person’s own contribution and participation.
By family assets, we mean:
Asset Category
Breakdown
Natural
Land
Water
Livestock
Aspirations
Motivations
Interests
Capabilities
Experience
Knowledge
Skills
Networks
Income
Savings
Collateral
Human
Financial
The programme focus is to identify appropriate and feasible ways within each family unit
(and within the wider community) to enhance the stock of these assets in a manner that
is consistently sustainable over time, that has a qualitative and quantitative impact on
the family’s life situation and poverty; and, crucially that enables the mentally ill person
to make an identifiable and consistent contribution. This contribution should not only be
seen to enhance the family’s stock of assets, including that of the mentally ill person,
but should support that person in the appropriate management and recovery from their
illness. In other words, it should provide meaningful work, which is recognised by the
family as a whole and is, in the broadest sense, therapeutic.
Process
Approach:
The main approach that Basic Needs is developing first recognizes the importance of
stability, by facilitating access to mental health services, promoting participation in the
existing self help groups (SHGs) and providing support for the household.
Once stabilized, mentally ill people are encouraged to choose to take up productive
employment. Initially, this may be non-remunerative, domestic work. We recognize this
as being of both intrinsic value as well as being an important stage of signaling to family
and the wider community that the person is stable and potentially available for
employment or other income generating activities.
125
In our pilot projects, the ratio of people returning to previous employment to those taking
up new income generating activities is of the order of 3.5:1. We recognize that the
return to previous employment may be the simplest, least stressful and lowest risk
option facing a mentally ill person and is to be encouraged. We must, however,
recognize that if poverty is a contributing cause to the development of mental illness (as
well as often creating a constraint on its successful identification and treatment) a return
to prior employment, though improving the family’s poverty situation, may not be a
satisfactory long-term developmental outcome. Thus, we seek to build on this important
and valuable intermediary step by supporting the mentally ill person’s access to
services that aim to address their life in poverty through extending the possibilities of
enhancing family assets through microfinance (credit & savings) and employment
training opportunities.
For some people, where recovery takes longer or during possible relapses, we aim to
involve the caregiver in income generation activities, while always maintaining a holistic
approach to the household seeking the inclusion of the mentally ill person at all times to
the maximum extent possible while always maintaining appropriate sensitivity to their
prevailing condition.
We aim to orient both SHGs, micro-finance and employment training institutions, so that
they are encouraged to provide access to support, credit and savings and training to
mentally ill people in ways that minimize risk and allow for the needs of a mentally ill
person, ways that especially recognize their potentially fluctuating stability and the
importance of minimizing stress.
126
o
Session 2 b
Income expenditure analysis
Model of income and expenditure analysis:
Expenditure of family X having two children - rough estimate of the monthly expenses
1. Expenses for the grains - 500 Rs
2. Expenses for groceries - 400 Rs
3. Expenses for milk - 150 Rs
4. Expenses for snacks - 160 Rs
5. Expenses for the vegetables - 140 Rs
6. Expenses for firewood/kerosene - 200 Rs
7. Expenses for Non veg food- 400 Rs
8. Expenses for flowers/agarbathi/camphor-100 Rs
9. School and tuition fees - 300 Rs
10. Expenses for buying fodder for the animals - 800
11. House rent - 500 Rs
12. Expenses for entertainment (cable charges, movies, exhibitions, circus)400 Rs
13. Expenses for ironing clothes - 80 Rs
14. Expenses for washing clothes - 120 Rs
15. Expenses for smoking/alcohol - 500 Rs
16. Electricity bill/telephone bill/mobile bill /water charges- 350 Rs
17. Expenses for the travel - 200 Rs
18. Expenses for buying face creams, powder & other make up equipments 150 Rs
19. Expenses for the cloths - 300 Rs
20. Expenses for unpredictable things (illness, festivals etc)- 200 Rs
5800 rupees for one month
Income source
Income for X family:
Income from agriculture: food grains worth rupees 18000 per year- 1500 rupees per
month
Income from the collie work (men) 100*15 days 1500 rupees per month
Income from the collie work (women) 80*12 days 960 rupees per month
Income from cows/buffalos 80* 30 2400 rupees per month
127
Session 3
Sustainable Livelihoods: 20 minutes
1. Trainer invites participants to share attitudes of families/community with regard to
people with mental illness (in the context of involving them selves in productive
activities).
2. Trainer invites participants to share reasons for low status for people with mental
illness in the community in small groups of 4.
3. Trainer invites group to presentation and categories the responses in the black
board.
4. Trainer summarizes the responses of the participants and links same to the self
worth of people with mental illness.
Trainer notes: attitudinal problems in the community (including us- .already formed
opinion that mentally ill people can not lead a normal life.), same need to be
dropped/reflected.
Bus Game: 10 minutes
1. Trainer invites 2 participants to be volunteers to be the bus driver
2. Trainer gives various options like (all men in one bus, all women in one bus,
all those who have passed 10th class exam in one bus, rest in other bus, All
those who are in debts will be in one bus etc)
80 minutes
1. Trainer asks the participants to write their family income (from all sources) for the
month in their note book.
2. Trainer asks the participants to list down the expenses for one week, trainer
gives example like money spent for milk, flowers, groceries, fuel, fire wood, for
their travel etc.
3. Trainer asks participants to divide their monthly income by 4, so that they can
arrive at weekly income.
4. Trainer asks the participants to compare the expenses to their income.
5. Trainer asks participants to priorities the expenses more essential to less
essential.
6. Trainer asks the participants how much was the relevant expenses in the last
week.
7. Trainer invites 6 volunteers (three men and three women) to share their
expenditures list.
8. Trainer invites participants to comment on the life style and the expenses of
every day
9. Trainer asks participants to reflect on the expenses for the family functions
(marriage, naming ceremony, death ceremony, puberty function, birthday
celebration etc). How much is the relevant expenses, in comparison with the
olden times?, How the relevance of the religious functions loosing? How people
are exhibiting their income in the family functions?. What are the facilitating
factors and what are the barriers (reasons for failures)
Trainer notes: direct and indirect expenses. Think about productive work not been
considered as income. If you buy chicken in the shop we would value it, if same been
got from the home. On the expenditure side reflect on spending on essential and non
essential things. When you spend on non essential things you will not have money for
spending on essential things. Reflect on the essential spending like, health, good
nourishment, education etc. Making savings as a habit to be self reliance/ self sufficient
etc.
128
Session 3
From Dependency towards Self Reliance - A Basic Needs India paradigm.
Poverty is more than low income and wealth is more than material possessions”.
Poverty being the cause and effect of mental illness has to be addressed from three
stages that is the past, present and the future. Basic Needs India Trust from its
inception in 2001 has tried to tackle and deal with the issue of mental illness from a
curative perspective with the identification of people with mental illness, treatment and
follow up procedures. Working in partnership with other NGOs certainly has had a
proven impact on the community. Any intervention aimed at upliftment and
empowerment of the marginalized and the poor should have a sustainable component
to it wherein the people will carry on with the activities and become progressively
independent and self-reliant.
This paper will focus on the Basic Needs India experience in facilitating the community
towards economic empowerment. Here the word “empowerment” conveys the meaning
that people be enabled “to get what they want on their own”. To base the program on
local reality is clearly a fundamental success. Based on the local reality it is evident that
starting business development services amidst the mentally ill population will be more
difficult than in favourable contexts. Keeping this in the background the economic
activities should be initiated and implemented.
Society for Community Organization and Rural Development (SCORD) a partner
organization of Basic Needs India which works in the Tanjore district of Tamilnadu
initiated the Micro Enterprise Development Program (MEDP) in its project area with the
help and support from Jan Sakthi Sansthan (JSS) a central government project. The
preliminary discussions bore fruits whereby JSS identified the potential entrepreneurs
for different trades and assured that the JSS team would provide training for the
community. Some of the areas which were of interest to the community are
a. Sambrani (agarbathi / incense stick) production and sales unit
b. Animal Husbandry (Goat and Sheep rearing)
c. Computer education
d. Tailoring and Embroidery
e. Color powder whole sale business and distribution
JSS has assured that training will be provided and appropriate support will be given
during the initial phase.
The step to come forward to collaborate with SCORD for the cause of mental illness is a
welcome measure. At the same time it is paramount to look into certain factors which
are of much pragmatic significance.
From a Mental illness perspective Micro Enterprise Development Program has to be
considered as a part of the rehabilitation process and not as a separate intervention.
Adhering to this view means to accept that MEDP would certainly promote recovery
among the mentally ill but won’t be totally successful in developing micro enterprises.
Considering MEDP as a part of the rehabilitation process, it will have a negative effect
129
on the sustainability factor. It will be a Herculean task for the stabilized people with
mental illness to gain a shift from a no loss-no gain to a profit-making zone. Ostensibly
this shift will happen after a considerable period of time whilst the time they reach that
position the competition will be high which would hinder their survival in the market.
To consider the time spent for identification of potential entrepreneurs from the
community is paramount step. A set procedure has to be followed. Providing
appropriate choice and preferences through continuous motivational support to the
people invariably substantiates the “bottom-up” approach towards development. In our
pilot projects (Basic Needs india) the study conducted by Nicholas Coloff and Dr.Anil
revealed that the ratio of people returning to previous employment to those taking up
new income generating activities is of the order of 3.5:1. Comparatively speaking the
return to the previous employment may be the simplest, least stressful and lowest risk
option facing a mentally ill person. This fact is recognized and encouraged by Basic
Needs India. Though the previous employment reduces poverty to a certain extent it is
felt that it is not practicable to suffice the absolute needs in the long run. In order to
create a long term development outcome emphasis should be given in the areas like
capacity building and motivational training, extracting more grant and credit facilities as
support measures and aiming for collaboration with other departments and institutions.
It is absolutely necessary to strike a balance between the rehabilitation model
(considering the activities as activities by itself to keep the people with mentally illness
occupied) and the standard business model. There has to be a common consensus in
proportionately sharing and adopting the significant features from both the models.
Since there is an already existing Micro Finance set up (SHG model) at the grassroots
level the same can be used as a platform to carryout the needs assessment so that
appropriate plans can be framed for the economic activities in consultation with the
people with mental illness and their family members. This above-mentioned exercise
would help us to understand the gap between the needs of the people with mental
illness and the existing program and the services. It would also reveal if they have
access to the services, awareness about the legalities and its implications and the level
of support from the society. A holistic approach through sectoral coordination
addressing mental illness will beyond doubt have a ripple of effect.
NGOs & Govt.
Society
Empowerment
Appropriate
Tech.& Training
130
As a first step to assess the house hold economies would result in analyzing the
financial burden of the family thereby addressing the needs and creating forward
linkages with the banks and other financial institutions. Technology harnessed wisely
through appropriate training will enhance human potential and people with mental
illness certainly are not an exception. As already said the ultimate goal of this venture is
to reclaim the mentally ill persons to normalcy and get them integrated in the Social
mainstream. While doing so the guiding principle will always have to be “help to help
themselves” as a permanent remedy and relief. The purpose of help should not be
paternalistic, making them perpetually dependent on others. On the other hand make
them stand on their own legs in the long run. Help in the form of Governmental, nonGovernmental and technological aids will all be like crutches only. The crutches have to
be removed at one stage and this will be for their own good. In this context the Chinese
saying is very appropriate to be remembered. “Instead of giving people a fish a day,
teach them fishing” is the philosophy of the whole paradigm. “From dependency to SelfReliance” is the thrust of our mission.
131
Session 4
Livelihood Interventions: 60 minutes
1. Trainer divides the participants in to four groups.
2. Trainer asks participants in the small group to list out the various livelihood
options/interventions seen at the community level.
3. Trainers ask the participants to reflect in groups on whether these interventions are able
to meet the financial needs of the individual or families.
4. Trainer asks group to discuss on why income generation activities provided was not able
to meet the financial requirement of the individual/ families.
5. Trainer invites group to present the group discussion.
6. Trainer summarizes and concludes the discussion on how the livelihood interventions
should meet the financial requirements of the family.
Trainer notes: consultation with the affected person and the family is the key
intervention. Self employment, group activity, family occupations are the options. Any
new initiatives, the affected person or the family should be given training to acquire the
required skills.
132
Session 4
Self Reliance- Basic Needs India’s Experience
Background
Basic Needs India (BNI) is a collaborative network involving groups such as community
based organisations (CBOs), non-governmental organisations (NGOs), research
institutes, statutory bodies and local community resources which are concerned for the
well being of the people with mental illness. The belief is that through capacity building
of the mentally ill, their carers and these organisations, the mentally ill can become selfreliant. This in turn will result in integration into their own families and the main stream
where they will be recognised as capable and contributing people within society. Such
capacity building will become a factor in the process of overall poverty reduction
amongst the communities with whom Basic Needs India is working. The above ethos
necessitated exploratory visits, meetings with concerned people and a consultation
workshop with mentally ill, their carers and CBOs. Through this process, the income
generation module evolved with three clear purposes.
Sustainable Livelihood to BNI Means: At Basic Needs India our understanding of
livelihood/income generation/self-reliant programme is as far as livelihood is concerned
family as a unit, people with mental illness are involved in gainful occupation, not sitting
idle/just brooding and warranting the care givers getting freed and people with mental
illness getting into meaningful occupation and earning money there by there is a
recognition for people with mental illness within their own family and community and are
involved in their own development process in the process meeting their own basic
needs and exercising their basic rights. In so doing it doesn’t create a further stress on
mentally ill person and it is to release the stress or it should be therapeutic. Don’t ever
measure people with mental illness productivity/incomes.
Purposes of livelihood :
> To enable people with mental illness to participate in a sustainable self- reliant
income generation programme leading them to exert their full potential within
their own communities;
> To enable people with mental illness to engage in activity, which is physically,
and mentally rewarding which thus in turn promotes improved physical and
mental well being;
> To enable the families of those with severe mental illness to undertake income
generation activities, which will serve to augment existing family income, thereby
alleviating the financial burden of caring for a person with health needs;
> To reduce drug intake over a period of time as people become successfully
rehabilitated with in their community.
> To provide an opportunities for families to come out of economic burden
133
FRAMEWORK
TECHNOLOGY
demonstration/training
MARKETING
SUPPORT
COMMUNITY/
CREDIT
SUPPORT
SELF
RELIANCE
INPUTS
SUPPLY
CENTRE
TECHNICAL
SUPPORT/
SERVICE
PROVIDERS
In the move towards self-reliance, the following factors are essential components:
1) Technology - the interested person should see the activity being carried out and/or
undergo a period of training to acquire the skills associated with that activity
2) Community/credit support - financial, material and other support is invariably
required and should preferably be available from within the person’s immediate
community or through locally available networking opportunities
3) Input/supply centre - materials/resources/equipment regularly required for the
activity should be available within the local area in order to maximise the income
ultimately available from the activity
4) Technical support/service providers - where necessary, for example in the case
of animal husbandry activities, a trained person with the necessary technical skills
should be available in times of need
5) Marketing support - there should be a viable, local and sustainable market for any
goods produced as a result of the activity
6) Care giver or family member will be associated in above process - by product
of involving family member will be in case of relapses care will be carried out in
business proposition
The choice of the activity in 1) is dependent on the availability of the factors listed in 2) 5).
134
PROCESS
Pre-requisite: Stabilisation of mentally ill person - means regular intake of medicine,
found improvement in association with CBO’s staff and Secondary partner
Ideal time: To start livelihood intervention
■
Group formation of people with mental illness and their care givers
People with mental illness and/or their caregivers will join groups formed at circle
level (5-6 villages). This process will be facilitated by Basic Needs India and carried
out by the local CBO. These groups will be the initial forum for identifying and
initiating local income generation activities and will provide an ongoing support and
self-monitoring facility for the members. This group will meet once a month
(minimum).
■
Foundation training to groups along with CBO staff
Participatory training to strengthen the groups will be carried out covering areas such
as the importance of group formation, group characteristics and behaviour (including
ground rules) and potential development and achievements of the groups
■
Identification and assessment of their capabilities as well as their needs
With the technical support of Basic Needs India staff, local CBO staff will identify the
existing skills of the members as well as explore their interests. Their existing
abilities, mental health condition and potential as well as their social and economic
needs will be considered carefully in this process.
■
Based on their capabilities identification of local viable trades
Following on from the above step and taking into account the factors listed above
(Framework) possible trades will be identified and proposed to the individual as a
potential income generation activity. To enable this, thorough research of local
resources will be carried out and a directory of resources for training and accessing
finance will be compiled.
■
Technical training in specific income generation activity
Individual members (or small groups of individuals where appropriate) will be
provided with access to the necessary exposure and training required for them to
undertake the chosen income generation activity. This training will include not only
the immediate skills necessary to carry out the trade but also associated skills such
as planning, marketing etc.
■
Networking with Micro Finance Institutes (MFIs) or credit support to the
groups through CBOs
Basic Needs India staff will train the local CBOs in methods of accessing credit from
local banks, agencies such as National Agriculture Bank and Rural Development
(NABARD) and other MFIs. The CBOs in turn will facilitate members of the groups to
access funds from these sources.
■
Monitoring of progress and evaluation of income generation module
135
CBO’s and Secondary partner staff will be trained to carry out continual support and
monitoring of the progress of members in their chosen income generation activities.
Basic Needs India staff in turn will monitor the support given and evaluate the
effectiveness of the technical and other supports (as listed in Framework). Mid
course corrections will be carried out as necessary and the process will continue.
Review:
Of the entire module, lessons learnt, quality of the programme, if necessary mid
course corrections and needs to be diversified. The whole property/resources will be
owned by CBO’s or Secondary partner and groups reflections of their own
experiences
■
Institutional training to groups along with CBO staff
Participatory training targeted at developing the vision of the groups towards forming
their own independent association/federation at taluk/district level which will in turn
network and work for change in the provision of services for and attitudes towards
people with mental illness, ultimately leading a move towards basic rights.
■
Documentation and Dissemination: of the whole process for larger audiences
ACTIVITIES:
Training:
■
■
■
■
■
■
■
■
■
On income generation and where it fits in the process of rehabilitation
of people with mental illness and their caregivers to CBO’s staff and
secondary partner
On assessment of people with mental illness and their caregivers
skills, capabilities and their interest in the area of income generation
On how to facilitate the people with mental illness and caregivers enter
into the existing SHG’s groups and /or initiating new groups as
necessary
To CBO’s/ Secondary partner staff regarding the process and benefit
of farming federation and supporting towards this goal
Where federation already exists orientation of members on income
generation module and facilitating their active involvement in
supporting and monitoring overall process
Facilitating the process of exploring local viable trades including the
option which may support local CBO’s/ Secondary partner towards
economic sustainability
Training on Agriculture, horticulture, animal husbandry and allied
activities to people with mental illness and their care givers with CBO’s/
Secondary partner staff
Identifying appropriate people/institution/organization to support
training in other areas/profession and facilitating CBO’s/Secondary
partner staff to support people with mental illness and carers in training
process.
Sensitisation of companies/institution/organizations to the possibilities
of integrating people with mental illness/caregivers into the training
programme or work place
136
Identification of local/state level micro-finance institutes (MFI’s) and
orientation regarding Basic Needs India approach
■ Facilitating linkages between intending CBO’s /Secondary partner
" Along with CBO’s / Secondary partner staff exploring the possibilities
of utilizing the services from interested MFI’s to support individuals/
groups in income generation activities
■ Strengthening existing system of CBO”s/ Secondary partner to monitor
and evaluate income generation activities which in turn feeds into
overall Basic Needs India PMS
■ Half - yearly review of the program with CBO’s staff / Secondary
partner to enable necessary mid-course correction or strengthening of
process
■ Annual meeting of all stake holders involved in income generation
module for review and planning
■ External evaluation during third quarter of 2003
■ Dissemination of experiences and learning to stake holders and wider
audiences through reports and case studies and use of websites and
journals
■
137
Session 5
Trade analysis : 60 minutes
1. Trainer gives input on trade analysis and share the trade analysis format
2. Trainer divides participants in to three groups, ask them to do trade analysis for 3
people, (a mentally ill woman wanted to grace cow, a mentally ill men wanted to
open a tailor shop, a mentally ill men wanted to start a welding/puncture shop)
3. Trainer invite group to make presentation of the trade analysis of each group
4. Trainer summarizes the presentation on trade analysis.
Trainer notes: market, quality (nil rejection) timely deliveries, exposure to seasons,
prevailing trends, fluctuations in input output (sensitivity and alertness in business)
138
Session 5a
Selection of an income generation activity
Questions to be asked
What materials or equipment would be required for production?
How much would they cost?
Who would buy the product?
How much would they pay?
How far away they live?
Will there be transportation problems?
What storage problems we may have?
What skills and knowledge would we need?
What facilities or land would be required?
How long would it take us to get started?
How long will it be before we start to make a profit?
Where could we get help or assistance?
What will be the long term/short term benefits to the community?
How can the community be involved in the project?
139
Session 5b
Identification of trade - a feasibility study profile
I. Personal data:
1. Name of the members
2. Age
3. Address
4. Education status
5. Disability
6. Family constellation table
Name
SI
Relationship
Age
Occupation
Income
Remarks
No.
II Data on trade
1. Desired trade:
2. Experience / skills related to the proposed trade:
3. Feasibility
(a) Raw material:
(b) Support from family / anybody in the family has already involved in the trade?
/The kind of support that the family would extend to this person for the trade:
(c) Anybody in the village is involved in this trade? I Their experiences / the risk
involved in this trade:
(d) Marketing prospects:
(e) Profit ratio:
4. Details of investment:
(a) Amount required for investment:
140
(b) Financial sources:
Individual contribution: Rs.
Loan Rs.
(C) Loan: BankIZZ] Organisation|—| Government scheme
□
(d) Rate of interest:
(e) No. Installments for repayment:
(f) Installment amount:
(g) Subsidy if any:
5. Details of re-investment strategies: If yes, how much?
Ill Details of sangha activities:
1. Name of the sangha to which the member belongs:
2. Number of meetings held in sangha:
3. Number of PWDs in the sangha: Male: /Female:
/Children
4. Total amount of savings in the sangha: Rs.
5. Utilization of savings:
6. Details of loans given to members for income generation:
7. Details regarding attendance of the member in the sangha:
8. Details of participation of the member in sangha activities
9. The total savings of the member:
10. Details regarding the member’s borrowing & its repayment status: (from Sangha)
SI
No
Date
Nature of Credit
Amount
Amount
repaid
Current
status
11. Details regarding loans obtained for income generation & repayment records:
141
SI
No
Date
Trade
Amount
Current
status
Amount
repaid
12. Details regarding the progress in the trade:
13. Details regarding the reasons & priority for the loan recommended for the member:
14. Relationship with the other members in the sangha:
15. Details of discussions & opinions of the sangha regarding the proposed trade for the
member.
16. Details of recommendation & guarantee by the sangha:
IV Action from federation/Organisation
1. Details regarding the meeting & the reason for recommendation by the trade
committee:
2. Details regarding the modifications/alterations by the committee, if any:
3. Final amount agreed to be given for the trade:
4. Details regarding the conditions for repayment/default:
5. Details regarding the follow-up measure:
Date:
Signature:
142
Chapter 6
Documentation and Advocacy
Trainees should be able to:
1. Gain an overall understanding of documentation-types and importance
2. Develop format (individual file) for documenting
3. Learn and use the various legislations and provisions related to persons with
mental illness
4. Have an understanding on human rights and international developments in
disability (UNCRPD)
Number of sessions: 6
Session 1: Need for documentation
Session 2: Individual file format and the quarterly report
Session 3: Advocacy
Session 4: Mental health legislations in India
Session 5: Provisions available for people with disabilities
Session 6: Human rights and UNCRPD
143
Session 1:
Need for documentation: 30 minutes
1.
2.
3.
4.
5.
Trainer asks the group to reflect on what is documentation
Trainer writes down the responses on the black board.
Trainer asks what are the types of the documents to be maintained
Trainer writes down the responses on the black board.
Trainer invites the participants to summarize the discussion on relevance and
possible uses of documentation.
144
Session 1
DOCUMENTATION
Documentation generally refers to the act of recording information, or the act of
collecting and organising documents.
Documentation is a process consisting of several activities, namely:
o Determining what information is needed and establishing means for
acquiring it;
o Recording the discovered information and storing such in appropriate
containers (called documents) or collecting already-existing documents
containing the needed information;
o Organizing the documents to make them more accessible; and
o Actually providing the documents to users who need the information.
USES
1. Establishment of historical records
2. Standard-setting for purposes of quality control
3. Direct assistance to victims
4. Pursuit of justice
5. Human rights education
TYPES
A document is a carrier or container of information. An equivalent term is information
material, or simply material. A document or material can be:
1. Textual or non-textual
2. Published or unpublished
A) Textual and Non-textual documents
A document or material is textual if it contains mainly written words. The following are
examples of textual documents: books, periodicals, statistical reports, legal documents
such as affidavits, catalogues, patents, and administrative records. The information is
usually printed on paper. The texts of many documents are now increasingly being
stored in electronic form such as files saved in computer diskettes.
Non-textual documents may contain some text but the most important part is the
information presented in some other form. Examples of non-textual documents are
photographs, maps, sketches, sound recordings, video recordings, artistic works and
monuments, films and slide shows.
B) Published and Unpublished documents
Documents may be published or not.
A published document usually has the following characteristics:
1. Made available to the public, such as by selling
145
2. Printed and packaged in a regular form such as a book, magazine or any other form
of publication
3. Produced with numerous copies
4. Available through established means of distribution such as bookstores and
newspaper stands
5. Carries a set of information such as title, name of author, name of publisher and other
related information that provides a unique and accurate description of the document as
a physical carrier of information. This set of information is referred to as bibliographic
description.
Some documents may not be printed and distributed, but are made available to the
public through websites on the Internet. There are numerous forms of unpublished
documents, each form used for a specific purpose. For instance, an affidavit is mainly
used in legal procedures. A data entry form on the other hand facilitates data retrieval
and collation of statistical information
Grey literature refers to documents which, while also available to the public, do not
conform fully to the above set of characteristics. For instance, only a limited number of
copies may be available, and not through the usual means of distribution. Common
examples of grey literature are conference papers, public statements and
denunciations, occasional reports by human rights organisations, speeches and
declarations, brochures, etc. Many of these documents are reproduced in limited
quantities, such as by photocopying. Non-governmental organisations account for a
large amount of grey literature, especially in situations where they had to establish
alternative information dissemination channels as their access to the mass media is
limited.
146
Session 2:
Individual file format and the quarterly report: 100 minutes
1. Trainer introduces the concept of case study, individual files and life stories
2. Trainer brainstorm with the group to arrive at the broad areas for case study
format (personal details, occupational history, marital history illness related,
premorbid personality, family details .environment and statistics etc)
3. Trainer divides the participants in to 4 groups, they are expected to list down the
areas of information under each group and give a rationale (basis) for all the
details that they will require or what purpose will the information serve.
4. Trainer invites group to make presentation on their discussion. The other groups
would contribute and clarify so that all have similar understanding.
5. Trainer summarizes the discussion reading out the format arrived for individual
file and the copy of the format for individual files will be shared with the
participants.
6. Trainer shares with the group copy of the quarterly report and agree up on the
quarterly report format and also include a section for the “changes tracked (follow
up information)” so that all partners have same understanding on the reporting.
7. The data base on the system will be displayed through LCD, and its use in filling
the quarterly report will be shown to them.
147
Session 2a
CASE STUDIES: Is defined as detailed analysis of a person or group, especially as a
model of medical, psychiatric, psychological, or social phenomena.
In our NGO Context, it is an in-depth study of one person. In a case study, nearly every
aspect of the subject’s life and history is analyzed to seek patterns and causes for
behavior. The hope is that learning gained from studying one case can be generalized
to many others. Unfortunately, case studies tend to be highly subjective and it is difficult
to generalize results to a larger population.
INDIVIDUAL FILES: Is a comprehensive set of information on a person cover various
aspects like physical, mental, emotional, psychiatric details. The information collected
should give an over all picture of the person’s situation .The file must also include
indicators that can be followed up on regular intervals to check if the client is making
progress or not. For examples, change in behaviour, symptoms etc.
LIFE STORIES: An account of the series of events making up a person's life as
explained by the person in question. The idea is to bring out the qualitative dimensions
of information that tends to be missed out some times in case files. The life stories are
written up in a more reader-friendly format .This can then be highlighted in awareness
building and advocacy campaigns.
148
Session 2 b
Guidelines for collecting information on the individual and the family/face sheet
a) Individual & family member’s details like name, age, sex, marital status,
education, occupation, number of children, number of earning persons and
dependents etc.
About individual illness
a) History of illness - when it started, since how many years, how it started
b) Causes/triggering factors
c) Symptoms
d) Type of illness
e) Understanding on the illness by the individual & the family
f) Treatment process/efforts medical including local/faith healing
Social aspects of the family
a) Type of family - nuclear or extended family
b) Other social problems/difficulties like history alcohol/substances
c) Single parent’s family, broken families, marital conflicts if any, divorce and extra
marital relationships etc.
d) Cultural beliefs and practices of the family
Family dynamics
a) Relationships within the family
b) Impact of positive and negative relationships on the individual
c) Human rights violation like not providing treatment, property rights, abusing and
assaulting, chaining and locking etc.
Impact of the illness on the individual and the family
a) Social impact - stigma, marginalization/discrimination, isolation within the family
and community
b) Economic impact/burden - earnings and expenditures, number of earning
persons and dependents, savings, education of children, rent, family
maintenance, food clothing etc.
c) Due to mental illness any physical health hazards within the individual
d) Psychological situation of the family
Treatment process prior program intervention
a) In depth understanding on the treatment process - medical and other methods
tried by the individual and the family, if he/she is on treatment which hospital,
from how many months/years person is on treatment, whether it is satisfactory
and supportive
149
b) Why the efforts put by the family failed
Program interventions
a) Since how many years the family is in the program, how the individual and family
is identified/ included in to the program
b) Over all program interventions (Individual, family and community) like education
& awareness on illness, right treatment and follow up, counseling, skill
training/livelihood supports, self help groups, inclusion of PWMI and family
members in to community groups, federations etc
c) Impact and out come of the program interventions (Individual, family &
community) in various areas like situation of illness, understanding on the illness,
changes in the social aspects, family dynamics, economic situation, knowledge
and information like part of self help groups, community groups and federation
150
Session 2b
Tracking changes through individual case files - model 1
MENTAL HEALTH - INITIAL ASSESSMENT FORM)
Date
Cluster Area
Field Staff
Field Coordinator
INDIVIDUALDETAILS
Name
Age
Client number
Sex
Education
Marital status
Residential address
Manner of identification/Referral source
Informant(s) during interview
IS CLIENT UNDER MEDICAL TREATMENT? IF YES
Name of hospital
Hospital registration number
Name of consulting doctor
Dates of identification
Diagnosis and medications
PRESENT COMPLAINTS| (Number each complaint)
Family
Individual
HISTORY OF CURRENT ILLNESS
When and how did the illness start and develop? (Recent major life events,
relevant marital history, history of mental illness, relevant medical history e.g.,
head injury, alcohol or tobacco use)
'
CPHE Koranic’0931 a
• v’.
151
US S3
Care and treatment given so far
CLIENT’S FUNCTIONAL PERFORMANCE
Client’s current daily activities
Personal hygiene/Self care (Ability to manage bathing, grooming, dressing,
toileting, etc.)
Home management (Ability to manage cooking, cleaning, shopping, finances,
childcare, etc.)
[CLIENT’S OCCUPATION, SKILLS, and INTERESTS] (Include income if appropriate)
Past
Present
ATTITUDES AND BELIEFS
CLIENTS
i Understanding of illness
ii Beliefs about others
FAMILY’S
i.
Understanding of illness
ii. Acceptance of individual
iii. Support and supervision provided to involve individual in family activities
and functions
COMMUNITY’S
i.
Understanding of illness
ii. Acceptance of individual
iii. Support and supervision provided to involve individual in community
activities and functions
iv. Active resources created to support individual
152
[SOCIAL SITUATION
FAMILY (Circle members that client resides with)
Extended or nuclear family
Name
Relationship
Age
Education
Occupation
/Income
Skills
Remarks
Primary caregiver
Difficulties and needs experienced by the caregiver and support needed
[OBSERVATIONS DURJNG THE VISIT
CLIENT (Facial expressions, restlessness, strange movements, rate of speech, mood,
level of cooperation, ability to answer questions, hygiene, smell of alcohol or tobacco)
FAMILY DYNAMICS
GOALS| (Goals that you will be addressing)
Client’s goals
Caregiver’s goals ( Goals of the Staff involved with the individual and the family)
ADDITIONAL INFORMATION
|FoIIow up|
Signature
153
Session 2 c
Individual file format: model 2
Status Report of person with Mental illness -
Date:
Staff:
Identifying information
Name of Person:
Address:
Age/ Date of Birth:
Sex:
Marital Status:
Religion:
Caste:
Occupation:
Avg. Monthly Income:
Information Given by: Self / Parent / Sibling / son or daughter / relative / other
Personal History
Educational Level:
Other skills/training:
Occupation:
Hobbies / interests
Description of personality before illness
Description of Relationship with:
Spouse/family
154
History on Mental illness
Symptoms and onset
Causes according to person and family
Family history of mental illness
Treatment taken previously & duration
Current status
a) Physical
Sleep
Appetite
Daily living skills
b) Mental
Behaviour/ Speech/ Emotions/ Feelings
Person’s activities at home
Activities outside the home
Family and Social information
Family conste lation
Relationship
SI Name
Age
Edn
Occupation
Remarks
Any disability/mental illness in the family:
Marital Life - duration and relationship
Economic status of the family
Combined family income
155
Cultural Beliefs
Attitude towards person with mental illness/ how does family members relate to mentally ill
person
Primary carer
Other family problems
Attitude of Community towards him/her
Community support
Date of inclusion in the CMHD programme:
I. CMH
Diagnosis
Present treatment and date of commencement
Regular/ irregular
Side effects
II. Sustainable Livelihoods
Livelihood activities/skills
Total Hours of work per day
Present Income
Livelihood source of family
Total Income of family
Membership in SHG/ other group
Loans/schemes availed
Other remarks
156
Ill Capacity Building
Participation in family decisions
Participation in social / community life
Community support
Present Needs of person:
Action plan:
Quarterly Follow up Report
I.
Changes in symptoms and medication
II.
Participation in Livelihood activities
Changes in income levels
III.
Participation in Family life (describe quality and level of participation)
Participation in community life
Changes in attitude of people/community
157
Session 2 d
Reporting Period:
Partner:
A. Community Mental Health
Severe mental
illness
Male
Female
Common mental
illness
Male
Female
Total
Total Number
Identified in the area
(brought forward)
New cases identified
during the quarter
Number actively on
treatment brought
forward
New cases referred
for treatment during
the quarter_______
Total
n
SMD
CMD
Total
Source of Treatment
i.
Camps
2.
Private practitioners
3.
District hospitals
4.
Local medicine
5.
Any other (Specify)
158
Total
SMD
CMD
Female
Male
Female
Mate
Female
Male
Side effect
Relapse
Brought forward
During the quarter
Number stabilised
Brought forward
During the quarter
Regularity
i.
Regular with medication
2.
Irregular with medication
3.
death
Drop outs
Brought forward
During the quarter
B. Livelihoods
I.
Caregivers
PWMIs
Male
Total
CMD
SMD
Female
Male
Female
Male
Female
Number actively
in livelihood
(stabilization)
activity as on 1st
quarter_______
New cases
involved during
the quarter
Total
159
CM I)
SMD
Male
Total
Caregivers
PWMIs
Female
Male
Female
Male
Female
Consultations to
discuss livelihood
issues
160
II
Source of Support
A. People gone back to
previous work
1 Agriculture
2 Collie
3 Animal husbandry
B. Taken up new activity
with the financial support:
1
2.
c. From financial institutes
1
2
d. From partners through
SHGs
1.
2.
e. Directly from partner NGO
1.
2.
3.
f. Accessed government
schemes
1.
2.
g. Taken up new activity
without financial support
1.
2.
h. Number of people with
mental health problems
undergone vocational
training
1.
2.
ICT
C. Capacity Building
PWMIs
Major
Male Female
I.
Caregivers
Minor
Male
Female
Male
Total
Female
Number actively in
SHG activity as on
1st April 2009
New cases involved
during the quarter
Total
II
Number
PWM1
Caregivers
Staff
Others
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
Number of
consultation
held with:-
Number of
awareness
workshop for:-
a.
b.
c.
d
e.
Number of cultural
and other events
conducted
1.Sports
2.Rallies
3.Street theatre
4.Exposures
S.Outings
Marriage of
people with
mental illness
162
D. Advocacy and policy
Advocacy
Description / Narrative
Programmes
Efforts made to
address the following
and by whom
- Human rights abuse
- Meeting government
officials
- Demonstrations
- Others
Celebration of events
World Mental Health day
Any Other
RESEARCH
Number of
individuals files
updated
Number of life
stories
Staff meetings
(mental health
Review meetings
(planning and
review)
163
Session 3
Advocacy: 30 minutes
1. Trainer shows video on mental health advocacy and ask participants what they thought
and felt about the video
2. Trainers notes down the responses on the board
3. Trainer gives the definition of advocacy
4. Trainer invites participants to share some of their experiences on advocacy activities.
164
Session 3
ADVOCACY:
Advocacy is a means of supporting and helping people to speak up or act for them selves. The
key aim of mental health advocacy is to empower people who use mental health services and to
protect their rights as citizens by helping them to get their views across. Empowerment is an
essential aspect of advocacy. It supports and promotes people's rights to speak and act for
themselves and to regain some control over their lives
Advocacy support is needed in the mental health services because people who use them can
feel and can be dis-empowered by the rules, procedures and people providing the services.
Decisions are taken that affect their daily lives and well-being, for example:
•
•
•
•
Being detained in hospital under a section of the Mental Health Act.
Being prescribed medication which has adverse physical side effects.
How much money they are entitled to receive under any welfare scheme.
Provision of suitable accommodation.
Advocacy can involve
Listening and giving information.
Encouraging the client to speak on their own behalf.
Liaison with different agencies.
Mediating so people understand each other.
Representing or acting on behalf of someone.
Some examples of advocacy:
Within hospital:
Difficulties in communicating.
Feelings of loss of respect and dignity.
Sense of being powerless.
Lack of information about medication, side-effects and entitlements.
Lack of support when feeling confused, frightened or intimidated.
Difficulties getting a diagnosis.
Supporting at CPA's, Mangers Hearings, Mental Health Review Tribunals.
Within the community:
•
•
•
•
Practical problems in accessing benefits, accommodation and other services.
Lack of understanding of severe mental illness.
Discriminatory attitudes and fear.
Pressures at work, college and other environments.
165
•
•
•
Strain within the family.
Difficulty getting a second opinion or a medical review.
Problems with police and courts.
There are a number of ways of delivering advocacy services. The main ones are:
•
•
•
•
•
Legal advocacy, which is provided by legally qualified advocates, usually solicitors.
Citizen advocacy, which involves long-term, one-to-one partnership between user and
advocate. This kind of advocacy tends to be more common in the learning disability field
that in mental health, but may have some role to play in the latter, particularly for people
with both kinds of problems or organic difficulties.
Formal advocacy usually refers to schemes run by groups which are not, by and large,
user-led. Co-ordinators are salaried and often advocates are paid. They usually are
prepared to act for both carers and service users. They are sometimes involved in giving
informed choices and mediating for clients.
Peer advocacy, where advocates are themselves, mental health service users.
Self-advocacy, which involves people speaking out for themselves
166
Session 4:
Mental health act and People’s with Disability Act: 60 minutes
1. Trainer introduces the concept on mental health and legislation, list out the legislations
related to mental health
2. Trainer distributes paper on the summary of Mental health and disability act to the
participants
3. Trainer divides participants in to four groups, two groups would read on the mental health
act, and two groups would work on the disability act.
4. All the participants in the group would read the paper and would write down the summary
of the acts
5. Trainer invites groups to make presentation on the summary
6. Trainer sums up the discussion sharing relevance of these acts in the CBR context.
(
(
<
<
<
<
167
Chapter 9: Research and Manpower development
Government and local authorities shall promote and sponsor research in order to prevent
disability, develop assistive devices to rehabilitate the disabled, identify jobs and develop
disabled friendly structural features in factories and offices.
Chapter 10: Recognition of institutions for persons with disabilities
Within six months of this Act being passed, persons running establishments or institutions for
persons with disability shall apply under this Act for a certificate of registration of the institution.
Chapter 11: Institutions for persons with severe disabilities
Persons having disability of 80% or more are considered to be persons with severe disability.
The Government shall establish and maintain institution for them. Where private institutions exist
which meet Government standards, they shall be recognized as institutions fit for persons with
severe disabilities.
Chapter 12: The Chief Commissioner and Commissioners for persons with disabilities
The Central Government shall appoint a Chief Commissioner for the implementation of the
provisions of this Act. The Chief Commissioner shall coordinate the work of the Commissioners
(in the States), monitor the utilization of funds given by the Central Government Commissioners
appointed by the State Governments shall have similar responsibilities at the State level. The
Chief Commissioner and the Commissioner shall take up complaints regarding deprivation and
non-implementation of laws, rules, orders and instructions issued by the Government or local
authorities for the welfare and protection of Rights of persons with disabilities.
Chapter 13: Social Security
The Government shall, within their economic limits, make schemes and undertake rehabilitation
measures for persons with disabilities, and grant financial assistance to NGOs to undertake
rehabilitation programmes for persons with disabilities. The Government where possible, shall
give unemployment allowance to persons with disabilities registered with the special
employment exchange for more than two years, and who could not be placed in any gainful
occupation.
I
Chapter 14: Miscellaneous
Anyone attempting to commit fraud and avail of benefits meant for persons with disabilities can
be punished up to two years imprisonment, and a fine up to Rs.20,000.
The Government shall have the authority to make the necessary rules and regulations to carry
out the provisions of this Act. These rules and regulations shall be issued in the form of
Government Orders (GOs) which have the approval of both houses of Parliament.
►
>
>
>
I
I
170
Session 4 b
Mental Health Act, 1987
The enactment of the Mental Health Act, 1987 is a mental healthcare delivery in India. It is not
simply a. cosmetic improvement over the outdated Indian Lunacy Act 1912, but represents the
conclusion of lenghty presentation by the Indian Psychiatric Society to the Government of India.
This Act came into force in April 1993, as per the Government of India order, even though it is
still in hibernation in some States.
The Mental Health Act is ‘an act to consolidate and amend the law relating to the treatment and
care of the mentally ill persons, to make better provisions with respect to their property and
affairs and for matters connected with or incidental thereto.
The Mental Health Act has the following objectives:
1.To regulate admission to psychiatric hospitals of psychiatric nursing homes, of
mentally ill persons who do not have sufficient understanding to seek treatment on a
voluntary basis and to protect the rights of such persons while being detained.
2. To protect society from the presence of mentally ill persons who have become a
danger or nuisance to others.
3. To protect citizens from being detained in psychiatric hospitals or psychiatric nursing
home without sufficient cause
4. To regulate responsibility for maintenance charges of mentally ill persons who are
admitted to psychiatric hospitals or psychiatric nursing homes.
5. To provide facilities for establishing guardianship or custody of mentally ill persons
who are incapable of managing their own affairs.
6. To provide for the establishment of Central Authority and State Authorities for mental
health services.
7. To regulate the powers of the Government for establishing, Licensing and controlling
psychiatric hospitals and psychiatric nursing homes for mentally ill persons.
8. To provide for legal aid to mentally ill persons at State expense in certain cases, the
Government of India has constituted a Central Mental Health Authority. Before
implementing the Mental Health Act in the States, the States have to take action
regarding the following:
i. To establish a State Mental Health Authority.
ii. To spell out guidelines for establishment of private psychiatric
hospitals and nursing homes.
iii. Formation of a Board of Visitors.
In the Mental Health Act, 1987, a modest attempt has also been made to bring mental illnesses
on par with physical illnesses, thus reducing the stigma attached to mental illnesses. The
Mental Health Act has modified certain terms and definitions. The Act uses the term mentally ill
171
person instead of lunatic, mentally ill prisoner, instead of criminal lunatic. Other new terms are
psychiatric hospital instead of lunatic asylum, psychiatric nursing home and psychiatrist. New
terminology and definitions are given in Chapter 1. The Mental Health Act has 10 chapters in
total, consisting of 100 sections.
Chapter 2 deals with establishment of mental health authorities at the Center and at State levels.
These authorities will regulate and coordinate mental health services under Central and State
Govern-respectively.
Chapter 3 lays down the guidelines for establishment and maintenance of psychiatric hospitals
and nursing homes. Also, there is a provision for a licensing authority who will process
applications for licenses. No private psychiatric hospital or nursing homes will be allowed to
function without a valid license, which has to be renewed every five years. There is also a
provision for an inspecting officer who will inspect the psychiatric and
nursing homes to prevent any irregularities
Chapter 4 deals with the procedures of admission and detention in psychiatric hospitals or
nursing homes. In addition to the five methods allowed by the Indian Lunacy Act of 1912, one
more method have been incorporated.
Chapter 5 deals with the inspection, discharge, leave of absence and removal of mentally ill
persons.
Chapter 6 deals with the judicial inquisition regarding alleged mentally ill persons possessing
property, custody of their person and management of their property. If the court feels that the
alleged mentally ill person is incapable of looking after both himself and his property, an order
can be issued for the appointment of a guardian, If however, it is felt that the person is only
incapable of looking after his property but can look after himself a manager can be appointed.
Chapter 7 deals with the liability to meet the cost of maintenance of mentally ill persons detained
in psychiatric hospitals or nursing homes.
Chapter 8 is aimed at the protection of human rights of mentally ill persons. It provides that:
1. No mentally ill person shall be subjected, during treatment, to any indignity (whether
physical or mental) or cruelty.
2. No mentally ill person, under treatment, shall be used for the purpose of research
unless:
i. Such research is of direct benefit to him.
ii. A consent has been obtained in writing from the person (if a voluntary patient) or
from the guardian/relative (if admitted involuntarily).
iii. No letters or communications sent by or to a mentally ill person shall be
intercepted, detained or destroyed.
Chapter 9 deals with the penalties and the procedure, while Chapter 10 proves for
miscellaneous sections.
172
The positive qualities of the new Act
The admission procedure are simplified to some extent
The two new provisions of the Mental Health Act in Admission procedure are:
1. Admission of minor (below age 18) by the parents/guardian.
2. Admission under special circumstances (maximum 90 days).
The old barbaric terminology has been changed with respect to psychiatric patients and
hospitals.
The establishment of Mental Health Authorities, both at the Centre .e State is a welcome step.
These authorities are expected to n as friend, philosopher and guide to the Mental Health
Services .Provisions have been made for establishing separate hospitals se who are under the
age of 16 years and also for those who are addicted to alcohol and other drugs and for other
special groups. Emphasis on outpatient care has been made to safeguard the human of the
mentally ill person. Stringent punishment has also been led for those who subject the mentally ill
to physical and mental indignity within hospitals.
Critical view about Mental Health Act 87
1. The notion of a care in the community has not been addressed in the current legislation.
No effort has been made to provide after care services for the discharged patients. There
seem to be no thinking over the alternative to hospital care.
2. Psychiatrists, running private psychiatric nursing home are facing too many medico-legal
problems, difficulties and interference in the administration with regard to:
a) Getting and renewing licences.
b) Board of visitors control over their nursing home.
c) Constituting a medical board for their day to day hospital
procedure
like
issuing certificates for admission
and leave absence etc.
to
and
discharge
3. Patients examined by psychiatrists and admitted in a psychiatric nursing home should not
be compelled to undergo further examination by medical and/or non-medical visitors. It
goes against the fundamental rights of a citizen or his family and such a exposure of any
responsible citizen or his family and disclosure of his psychiatric illness to the knowledge
of the public may amount to indignity and cruelty.
4. In the present act the matter of consent and competence has not been adequately
addressed.
5. Does an involuntary admission (Eg: admission through a reception order) necessarily
imply competence? Can drugs and ECT be given without any informed consent? What is
the statutory criteria for competence? Who will judge competence doctors or the judges?
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Session 5
Provisions available for people with mental illness:
45 minutes
1. Trainer asks participants to list out the provision available for the marginalized people in
the state.
2. Trainer asks participants to brainstorm on how needs of people can be met from the
existing provisions from the government.
3. Trainer shares with the participants their experiences of availing benefits from the poverty
alleviation schemes.
4. Trainer shared about 3% reservations for people with disabilities in all the government
schemes.
5. Trainer concludes the discussion inviting comments how to educate the government
official/ panchyaths/community on the allocating 3 % of funds for the disabled.
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Session 5
Provision available for the people with disabilities in southern states
(will be sending it later)
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Session 6:
Human rights and UNCRPD - 90 minutes
1. Trainer introduces the concept of human rights, define what rights are.
2. Trainer divides participants in to three groups, each group would discuss on the needs of
different age groups (0-18 years, 19 year- 35 years, and 36- 80 years).
3. Trainer distributes the small KG card boards asks group to convert their needs in to their
rights in the card boards.
4. Trainer asks group to brainstorm on the rights of people with mental illness.
5. Trainer asks group to reflect on how rights of people with mental illness been denied in
the community.
6. Trainer shares with the group on the rights of people with mental illness
7. Trainer divides the participants into three groups again
8. Trainer distributes 3 different Role plays and gives 20 min time for preparation.
9. Each group will come and perform the role play for not more than 5-7 min each, (areas
covered are Health, inclusion in Community and Home and Family)
10. Reflections from the group on each role play.
11. Trainer introduces UNCRPD and UN Conventions by distributing the papers.
12. Trainer makes a short (5 min) power point/poster presentation on UNCRPD and UN
Convention.
13. Trainer asks group to list out incidence of denial of rights, and asks group to brainstorm
on the needs/ services required for the person to lead life with dignity.
14. Trainer invites participants to reflect as an individual about the rights they are entitled are
they enjoying these rights.
15. Trainer invites participants to list down what the group learnt about UNCRPD and UN
Conventions
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Session 6 A
HUMAN RIGHTS
Human rights are rights inherent to all human beings, whatever our nationality, place of
residence, sex, national or ethnic origin, colour, religion, language, or any other status. We are
all equally entitled to our human rights without discrimination. These rights are all interrelated,
interdependent and indivisible.
All human rights are indivisible, whether they are civil and political rights, such as the right to life,
equality before the law and freedom of expression; economic, social and cultural rights, such as
the rights to work, social security and education, or collective rights, such as the rights to
development and self-determination, are indivisible, interrelated and interdependent. The
improvement of one right facilitates advancement of the others. Likewise, the deprivation of one
right adversely affects the others.
The basic rights and freedom, to which all humans are entitled, often held to include the right to
life and liberty, freedom of thought and expression, and equality before the law.
Human rights entail both rights and obligations. States assume obligations and duties under
international law to respect, to protect and to fulfill human rights. The obligation to respect
means that States must refrain from interfering with or curtailing the enjoyment of human rights.
The obligation to protect requires States to protect individuals and groups against human rights
abuses. The obligation to fulfill means that States must take positive action to facilitate the
enjoyment of basic human rights. At the individual level, while we are entitled our human rights,
we should also respect the human rights of others.
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RIGHTS OF THE PEOPLE WITH MENTAL ILLNESS
The people with mental illness have a right to
> The same fundamental rights as their fellow citizens including the rights to a decent life,
as normal and full as possible
> Legal safeguards against abuse
> Appeal
> Necessary treatment in the least restrictive set up and the as far as possible to be treated
and cared for the in the community
> Rehabilitation
> Personal autonomy, privacy, freedom of communication
> Education
> Economic and social security
> Training
> Family and community life
> Employment
> Protection against exploitation ad discriminatory, abusive or degrading treatment
Find below a more detailed explanation of the rights enjoyed by all the citizens of the country
and this includes persons with mental illness
1. Right to inclusion
• Inclusion in disability
• Entitlements across sector for \persons with psycho social disabilities
• Right to form support groups and associations
• Right to inclusion in any development process
• Right to life free from Stigma and discrimination in all walks of life
• Right to dignity
• Right to find inclusion in mainstream life
2. Right to information
• Relating to policy and law
• Services , resources structure
• All types of treatment
• Consent in medical non medical research
3. Right to life
• Right to violence free environment
• Right to bodily integrity
4. Right to food security
• Right to nutritious food
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5. Right to political participation
•
•
•
Right to vote and contest elections
Right to hold public office
Right to be a member of statutory bodies: state national level committees MHA
6. Right to Liberty
• Minimise involuntary treatment and maximize participation
• Right to least restrictive environment
• Right to free movement
7. Right to livelihood
• Right to poverty alleviation and employment
• Right to free vocational and skills training
• Right to entrepreneurship and alternative employment
• Right to equal wages as any one else
8. Right to integrated, quality mental health care
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Right to rational, affordable and accessible medication
Right to non drug approaches, addressing well being and not just symptom reduction
Right to quality health care
Right to information about diagnosis, prescriptions and treatment - both medical and
non medical
Right to early psychosocial intervention for especially children and young adults
Right to have different means and services in the community including bare foot
workers
Right to quality time
Right to privacy
Right to standardized comprehensive and multi- axial assessment and care
Right to continuity in care
Right to socially and technically audited system of care
Right to non-hierarchical and non abusive forms of care
Right to be respected
Right to confidentiality
Right to dignified treatment
Right to decide who is one’s family/support system
9. Right to self determination
•
•
•
Right to Family, love, relationships
Right to positive identity construction
Right to choose treatments
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•
•
•
Right to consent to treatment-medical/nonmedical
Right to refuse treatment- medical/non medical
Right to autonomy
10. Right to Inclusion in Law & Policy Making
• Right to legal aid
• Right to grievances redressal
• Right to participation in review of acts and rules relating to mental health
• Right to laws which enable rehabilitation
• Right to inclusion in all statutory decision making bodies
• Right to be recognized as equal before law
• Right to necessary assistance
• Right to simplified procedures in accessing justice
11. Right to Well Being
• Right to Health
• Right to Play, recreation and leisure activities
• Right to participate in social, cultural and community life
• Right to well being at all 3 levels- preventive, promotional and curative
• Right to self understanding, self care and self growth
• Right to routine, recognition and resilience
• The role played by care givers be recognized
12. Right to socio economic security
• Housing
• Insurance
• property
13. Right to education
• Right to continuing free education beyond the age of 18
• Right to non discrimination in all educational settings
14. Right to rehabilitation
• Right to non custodial care
• Right to safe environments
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Session 6 b
UNITED NATIONS CONVENTION on the RIGHTS of PERSONS with DISABILITIES
(UNCRPD)
1O Adopted on 13 Dec 2006,
2. Opened for Signature on 30th Mar 2007
3. India signed on 30th Mar 2007 and ratified on Oct 2007
4. The Convention on the Rights of Persons with Disabilities received its 20th ratification on
3 April 2008 and the Convention and its Optional Protocol have come into force 30 days
later (3 May 2008)
5. It is a Human Rights Convention
6. Objective
a. To promote, protect and ensure that All human rights and freedoms of all
people with disabilities are enjoyed, promoted and protected
b. The dignity of people with disabilities is respected
7. The Convention, in Article 1, further does not limit to only the 7 disabilities (Blindness,
Low vision, Leprosy-cured, Hearing impairment, Loco motor disability, Mental retardation
and Mental illness) that have been mentioned in the Persons with Disabilities Act but has
opened up a wider definition as - “People with disabilities who have long-term
impairments, for example, physical, psycho-social, intellectual and who cannot get
involved in society because of different reasons, such as attitudes, language,
stairs, and laws, which prevent people with disabilities from being included in
society.” This broad based definition and the recognition of various barriers posed by
society assists us to develop a more holistic and sensitive approach in addressing the
discriminations faced by persons with disabilities in society.
8. The CRPD is quite a long document (50 articles!)
9. Articles 1 to 9 - General Application - Purpose, definition, principles, women with
disabilities, children with disabilities etc
10. Articles 10 to 20 - Civil Political Rights - Right to Life, Equal before Law, Freedom
from Torture, Exploitation, Violence, Abuse, Liberty of Movement, Being included in the
Community
11. Articles 21 to 30 - Socio Economic Cultural Rights - Education, Health, Livelihood,
Social Protection, Participation in Cultural life
12. Articles 31 to 40 - Implementation and Monitoring Measures - Data collection, reports
13. Articles 41 to 50 - Rules that govern the operation of the Convention - translations,
amendments
14. Further, this convention by design is not limited to only Govt, establishments. The
Convention states that private businesses and organizations that are open to the public
have to take initiatives to “eliminate barriers that people with disabilities face in
buildings, the outdoors, transport, information, communication and services”.
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15. What are the expectations from this Convention
a. Increase the visibility of PWD
b. Clarify the human rights of PWDs, and ensure governments make legislative and
programmatic changes for its implementation
c. Establish systems for comprehensively monitoring the human rights situation of
persons with disabilities
d. Establish systems for international cooperation, through which governments,
disability organizations and other actors can share knowledge and ideas and work
together to improve the lives of PWDs.
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Session 6 c
UNCRPD
Rehabilitate Disabled Persons
Rehabilitate Society
Charity, Medical treatment
Rights
Adjustment to the norm
Acceptance of differences
Exclusion
Inclusion, participation, citizenship
Little consultation
‘Nothing about us without us’
The CRPD and the Right to Work
Shift in focus
Segregated employment
Open Labour Market
Petty trading
Small enterprises
No legal provisions
Limited choice
oo(=C>
Coverage by employment laws
Work freely chosen or accepted
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Session 6 d
Role Play
1. Getting health care:
Actor: a person needing health care
Co-actors: the person’s friend and a nurse or doctor
Scene: the local clinic
A person with a disability needs treatment for a minor injury. The nurse looks only at the
person’s friend. The nurse asks the friend about the problem. The nurse does not ask the person
who has the problem. The person tries to talk anyway, but the nurse keeps talking to the friend.
2. The teaser
Actor: a lady worker who is being teased
Co-actors: a worker who is teasing and two workers who are watching
Scene: the workplace
A worker is busy doing her job. Another worker comes up and starts teasing her. She says, “You
are slow.” Two other workers are watching. They do not know what they should do. The teaser
will not stop the teasing.
3. The meeting
Actor: a person trying to speak at a meeting
Co-actor: a person who keeps interrupting
Scene: a community meeting
A person is trying to speak at a meeting about buses. They want to tell how they need more
buses. They want to tell about how they can’t get a job without a way to get there. It is their turn
to speak, but another person keeps interrupting.
4. One small step
Actor: someone who uses a wheelchair
Co-actor: the manager of a store
Scene: a store
A person who uses a wheelchair likes to shop. His favorite store is not accessible. There is a
small step in front of the door. So, the person needs to have a friend along to help. Or he must
wait until a stranger comes along to help. The person is meeting with the store manager to talk
about this human rights problem.
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Chapter 7
Project implementation
Trainee would have an understanding on
1. Advantages/ merits of including mental health in to development work
2. Consultation
3. Importance of home visits and Individual rehabilitation plan
4. Tracking changes through individual case files
5. documenting baseline
6. Reviews and evaluation
7. Understand the difference between ethics and life principles
8. Understand the different ethics involved while working with people and emotional issues.
9. Understand the need for empathy.
10. Understand some professional work ethics.
Number of sessions: 8
Session 1: Merits of including mental health in development activities
Session 2: Consultation
Session 3: Importance of home visits and individual rehabilitation plan
Session 4: Tracking changes in the individual files
Session 5: Base line
Session 6: Networking and Alliance building
Session 7: Work ethics
Session 8: Reviews and Evaluation
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Session 1
Merits of including mental health in to development work -45 minutes
1. Trainer divides the participants in to 3 groups.
2. Trainer asks groups to discuss on ‘mental health a development issue?’ ‘Can it be
included in the CBR programme’, if yes how they would include in their existing CBR
programme?.
3. Group presentation.
4. Trainer shares BNI experiences with the partners and its merits of including mental
health.
0
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Session 1
Community mental health and development approach:
People and the community are the biggest resources available for the community mental health
services. Many of the mental health problems can be effectively dealt by the people and within
resources available close to them. Large-scale dissemination of knowledge and skills to people
would help in reducing stigma attached to illness. Building knowledge and awareness of families
can make the real difference, their by PWMI become integral part of the community, participating
in all social and cultural activities.
Strengths of development approach for meeting the needs of people with mental illness
in their own communities:
1. Promotes community participation and community ownership of the programme.
Ccommunity participation encourages planning, developing and monitoring the
programme.
2. Active involvement of mentally ill people and their families in all their issues of concern
instead of them making passive recipients
3. Integration of mental health in the development process including transfer of skills to
home and the community thus minimising the need for qualified professionals. This is
more cost effective
4. The medical approach alone is not a comprehensive approach. Unless special focus is
given to the expressed needs of people with mental illness and their families, recovery will
remain inadequate.
5. Promotes better social integration and mainstreaming by ensuring that people with mental
illness have access to same benefits and services as others in the community where they
are working.
6. The integration implies high degree of collaboration between different sectors, such
coordination work better local.
7. Mental illness can be treated with simple, relatively inexpensive drugs. Only a small
percentage requires institutional care, hence majority can be treated and taken care in the
community.
8. Early diagnosis prevents unnecessary investigation and promotes early recovery,
resulting in attitude change in the community that most disorders can be treated in the
community.
9. Increased coverage because interventions are decentralized.
10. Negative attitudes / stigma attached towards illness will be challenged as there are more
chances/opportunities for people with mental illness to recover and lead a good quality of
life.
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Session 2
Consultation - 90 minutes
1. Trainer divides participants in to two groups
2. Trainer assigns the group to do a role play on consulting community members, while
one group performs the role play other group will be observer.
3. Trainer instructs group to decide one animator, who would facilitate the discussion
4. Trainer allows group to have discussion and decide on the script for the role play,
agree up on the group to be consulted.
5. Trainer invites the animators to share about the community group with whom he/she is
consulting and on the issue.
6. Trainer invites group to perform role play on consulting the community
7. Trainer invites comments from the observer to share their observations on the role
play and in particular the animation
8. Trainer invites other group to perform the role play, and observing group would share
their comments on the role play and in particular the animation.
9. Trainer summarizes the discussion sharing his comments and on the skills of the
animation.
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Session 2
Consultation
Objective: To get to know people, their understanding of themselves, their present status and
encourage participants to express/voice their feelings, needs and aspirations. In the context of
people with mental illness, the participants would include people with mental illness, family
members (caregivers) and community workers.
Pre-consultation: Notice of meeting stating starting time, venue and purpose reaches the
participants well in advance. Ensure travel plans and escort facilities where required. Ensure
both women and men participate in the consultations.
Logistics: The right venue and environment help participants to interact with each other.
Drinking water, toilet facilities, refreshments, enough newsprint, marker pens, etc., are other
essential requirements. Participants feel familiar and comfortable.
Process: A trained facilitator/animator would undertake the process. S/he would adhere to the
topic guides. For the first consultation the topic guides would include:
•
•
•
•
•
•
•
•
•
•
Greetings & ice breaking
Introduction to the day’s proceedings
Introduction of participants
Permission to process documentation and photographs
Setting of Ground Rules for the conduct of the programme
“My World” constituency mapping exercise
Explanation and debriefing of mapping exercise
Needs discussion (group exercise) followed by presentation & discussion in a big group
“What Next?” again group exercise followed by presentation and discussion
Debriefing - facilitator, key people from the organization and process writer
Process writer would be outside the circle and simply captures the content, context and even the
movements and moods of people.
Facilitator/Animator sticks to the sequence eliciting participation from every one. Does not break
the silence instead uses the silence to get life to the group. When required asks participants to
repeat what s/he said so that the group understands the depth and intensity of that particular
statement. Animator encourages reflections, debates among the participants without losing the
sight of purpose and good use of time. One has to be sensitive to emotions and at the same
time not to focus on one person so that others lose interest meaning sensitive to every one.
Group sizes need to be appropriate for every one to participate and their needs, if any, have to
be met in time. After each presentation clarifications to the queries have to be drawn from the
participants themselves. Persons with behavior problems may get up and go out. Some one
should mind them but not force them to behave themselves in the group.
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Points to remember (for Animator):
•
•
•
•
•
•
Communicate in the common understandable language
Not to misinterpret information/expressions
Listen with attention
Mind your body language
Position yourself appropriately e.g. not showing your back while talking
Repeat their expectations/decisions made e.g. have I heard you saying ‘you want to get
married’.
Close: Thank the participants for their frank sharing, especially for the commitments
made/action plans arrived, and any appropriate things done by them during the day. End with
the hope they have brought in. All the materials presented by the participants get collected by
the process writer.
Debriefing: The facilitator/animator, process writer and the key staff from the organization
debrief on every aspect of the day’s proceedings and that becomes the part and parcel of the
process document.
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Session 3
Importance of home visits and Individual rehabilitation plan: 120 minutes
1. Trainer divides the participants in to 4 groups
2. Trainer provides case studies (at the time of identification by the field staff) and asks the
groups to prepare follow up plan based on their learning experience and their field
experience.
3. Trainer ask one of the group to play a role play about the case study given to them, and
the CBR worker visiting them, would design the individual rehabilitation plan along with
the family.
4. Presentation by 3 groups
5. The trainer discusses each case study and helps them to make individual rehabilitation
plan reflecting community mental health and development activities.
6. Trainer would ask the group to observe the role play and document the proceedings of
the home visits.
7. Role play by the 4th group
8. Trainer invites comments from the group on the role play - ‘home visits’
9. Trainer shares his experience on the Home visits.
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Session 3 a
Case study I
Muniyamma is 45 years old married and living in one of the slum communities in Bangalore. She
is basically from Tamilnad and migrated to Bangalore some decades back. Her life started as a
daily wage worker at construction sites and she lost her parents when she was very young. Life
is very hard to live as unmarried single women in the urban area, her situation also made her to
think and she decided to get married. Finally the community in which she was living supported
her and she got married to a person who was living in the same community who is also an
orphan living alone. After few years of marriage she gave birth to a baby boy and the family was
a happy family. Few years later unfortunately the child developed some health problems and in
spite of all kinds of efforts he could not survive and she lost her son. With this incident her
dreams were shattered and she was mentally disturbed. She lost her hopes in life and she
became hopeless in life. Adding to the situation her husband developed blood sugar and
Asthma and he was struggling for his life. Poverty and lack of family support really shook the
couple and they could not take proper care and treatment and within a short period after the
death of the child he also passed away. Muniyamma who was full of sorrow from the childhood
could not gulp the situation (death of her husband) and she became mentally ill. She developed
severe mental illness and she started wondering in the communities, not aware of personal
hygiene and many times she wondered without clothes in the community. She used to bring all
garbage from roadside to her house and the house was stinking like anything. Not aware of her
appetite and meaning to her life. In and around community is though sympathetic towards her
they are not able to support her because even community is confused on her behavior and the
situation. Some times they provide food for her and the old clothes. Community is aware that
she is in a serious condition and the reasons for her situation. But they are not aware that she is
having illness. Looking at her wondering behavior and unhygienic appearance no body wants to
talk to her and few times police took her to beggar home in Bangalore, where they will keep
these kinds of beggars and wondering persons temporarily and send them back to their
communities. So to conclude she is mentally ill, living alone and though community is aware of
the situation they are not able to support.
Case study II
Sunitha 34 years old married woman and having two children. Daughter is 6 years old and son is
3 years old. Her husband Raja is a laborer in a whole sale market in Bangalore. His job is to load
and unload the goods from the lorry. He is a hard worker and earns reasonably fare amount of
labor/money every day. But he is addicted to alcohol and most of his earnings are spent on
alcohol. Left out money is given to the family maintenance. They don’t have a house, not even a
hut and they are living on the roadside. A small place on the road side very next to the market is
occupied and covered with plastic bags and they are living in that thatched place. One day Raja
was beating Sunitha very badly and one of the shop owners who was watching the scene went
and stopped Raja and scolded not to beat his wife. But Raja suddenly reacted and said she is
mad and she never listens to me and at times when she is out of control she gets beatings. Next
day morning hearing about the situation one of the development workers of the organization who
was doing some development work for the laborers in the community intervened and interacted
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with Raja. He started narrating the story and he said my wife some times suddenly starts beating
the children and shouting without reason and through out night she will be talking to self. Many
times when she goes to the toilet she had complaint that she saw her mother’s spirit who is no
more. The story was interesting and the development worker started digging the story and asked
Raja when she behaves like that what is your response? He said some times I also felt she is
possessed by her mother and I took her to some faith healers and tried my level best to treat
her. Taking her to faith healers requires fare amount of many, the faith healers demand money
for each visit. So I decided instead of taking her to faith healers, why not the same treatment can
be given by me and I started treating her with neem leaves along with beatings when ever she
behaves like that. It was interesting and at the same time sad to hear about their understanding
on her illness. Later the development worker interacted with Sunitha and she narrated the story.
When she was 14 years old she saw her mother dieing. Sunitha’s mother developed extra
marital relationships and husband could not accept and he poured kerosene and set fire and she
was shouting and flames were seen. Sunitha was the witness to the situation but she could not
support her mother. This incident was the triggering for her illness. She developed mental illness
after the marriage or when she was a child is not clear. But at present she is having severe
mental illness. She is hallucinating and has the feeling of possessed by her mother and not
interested in taking care of the children. Always shouts and quarrels with her husband. Raja is
more worried about her behavior, children and she also expressed the fear and insecurity and
sexual exploitation during his absence as she is not aware and the place is a market area full of
alcoholics.
Case study III
Shankarappa 24 years old studied up to PUC suddenly started telling the family members that
he could see the God. Lord Venkateshwara and Narasimha are visible to him. Even in dreams
he could see Thirupathi temple. At the same time he also shared with the family that a king
cobra with 5 heads spiting blood out if its mouth is visible in front of his eyes and he is very
afraid and he could not concentrate on his work and his daily activities. Family is astonished and
surprised at the same time they were confused what is going on. Immediately looking at the
situation his brother Seenappa took him to temple and they offered Pooja and the family had the
feeling that some rituals and religious practices will solve the problem. Even after performing
some rituals and practices the situation was the same. The second thought which developed in
the family is some body has done black magic and some evil spirit is possessing Shankarappa.
They also approached faith healers and the outcome was the same. One of the BNI partner
organization staff identified the person and asked the family to come and attend consultation
meeting. During the consultation meeting Shankarappa expressed the same feelings and it was
very clear that he has developed severe mental illness. He was looking very afraid, aggressive
and suspicious about his brother and the group. He was restless and agitated. Later the
development worker visited his family and started interacting with the family. According to the
information given by the family members Shankarappa is a very innocent and hard working boy
and after completing his 12th standard he joined some private company and was working since 2
years. Few months back suddenly an astonishing change occurred in his behavior as mentioned
above. Neither the family nor the neighbors are able to find out the causes/reasons for his
abnormal behavior. Few weeks later he was taken to the hospital forcefully but he is not ready to
193
take medicines and symptoms got worst. With great difficulty the development worker was able
to relate with Shankarappa and he came to know that he left the job because in the company
where he was working one cheque was missing and the company started suspecting and
blaming Shankarappa. So out of humiliation and frustration he left the job. He narrated another
story saying he was staying with his friends for about a year while working in that company and
with the influence of his friends all the five including him one day had sex with one of the sex
workers in the city and later he developed some infection in the genital organ. So he is confused
and at the same time afraid.
Case study IV
Lawrence, a 20-year-old boy discontinued his studies as he was not able to pass his 7th
standard since the age of 15. He started working as a helper under a contractor at the
construction sites. He was honest in all his dealings and gave his earnings to his parents. He
had lot of friends where he was living. His evenings were spent in the company of his friends,
playing cricket, football etc. One of his friends was in love with a girl residing in the
neighborhood. His friends used to tease that girl often. One day a group of 5 youth attacked
Lawrence and his friends unexpectedly. Lawrence was also badly assaulted as he was part of
the group. He had a head injury and was hospitalized. Few weeks later he developed excessive
fear and was not ready to go out of the house. He would scream constantly and sound very
abnormal.
Lawrence’s sister speaks of the incident and what followed. “He was an ok boy. Did not do well
in the school and discontinued his studies. He started learning carpentry and the trainer was
also a contractor. Hence, he had no problem in getting work. One day he did not feel normal. He
was disoriented, speaking unnecessary things and behaving abnormally. We took him to various
healers and offered prayers in the church but there was no improvement. One day he ran away
from home. We searched all over but did not find him. I think after more than two months his
brother found him in another part of the town. When he was brought home, my heart sank and I
wept. Every one was in tears. He was in his underwear and had an old coat on him. Even now if
I think of that scene, some thing happens in my stomach.”
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Session 3b
Individual Rehabilitation Plan
Individual rehabilitation plan has to be developed for each individual; hence it is different for
each individual. While planning the individual rehabilitation plan, need to involve person and the
family in the planning phase. Down below is given the areas to be considered while planning for
the Individual rehabilitation plan.
The plan must include
•
•
•
•
Information about the illness and about current circumstances
Details about any treatment received previously and its outcome
Information on the functional impairment caused by your illness
Details about the what need to be done (goal, contact persons, follow-up methods and
responsibility for care)
Medical rehabilitation
Identification of person with mental illness
Rapport building with the person and the family
Educating family about the illness
Motivating families for taking treatment
Assessment - history of the illness
Consultation of person with mental illness and in the larger groups
Referral for the assessment diagnosis and treatment
Educating them about the need for taking treatment
Dealing with side effects of medicines
Follow up services
Home based support
Monitoring the medication
Psycho-education
Bare foot counselling and psychotherapy services
Dealing with drop outs
Identifying relapses and referring back for care services
Understanding and assessment family dynamics
Attending caregivers meetings
Documentation of individual files
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Economic rehabilitation
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Dealing with the negative symptoms
Motivating the person for involving in house hold chores
Helping the person involving in productive work
Involving in group activities
Encourage the person to go back to previous work
Discussion with the employer about the condition of person with mental illness
(reasonable accommodation)
Involving in income generation activity like cow/goat/ramlamb rearing
Linking groups to banks for micro credit loans
Skills assessment
Referring for vocational training
Encourage savings
Social rehabilitation
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Integration in to self help groups
Involving in family activities
Involving in community activities
Awareness programmes in the community
Accessing poverty alleviation and disability schemes
Resource mobilization in the communities (world mental health/world disabled day)
Educating community about the ‘rights’ of the individual
Educating families and the communities about their entitlements and the government
responsibility in meeting the needs of people with mental illness
Formation of care givers forums
Formation of affected groups/ forum so that they can create platform for raising their
voices
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Session 4
Tracking changes through individual case files: 60 minutes
1. Trainer invites participants to share on the different types of documentation they would
maintain in their work.
2. Trainer lists down all the responses on the black board.
3. Trainer asks the participants why they are documenting?, how it will be used? (based on
the list prepared).
4. Trainer shares the types of documentations maintained for the community mental health
and development programme.
5. Trainer asks the three volunteers to share the documentation of the role play (previous
session).
6. Trainer shares his observations on the documentation and shares on the expected
documentation in the individual files (changes at individual, family and community in the
process of rehabilitation)
7. Trainer shares on the individual format, takes them through the format. Distributes some
models of the documentation (local language)
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Session 4
Importance of documentation
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Records of the home visits made by the field staff helps to see the overall progress
of the client.
Keeping a stock of medicines helps to purchase the medicines according to the
need and to prepare a statement of budget to buy those medicines.
Life stories - will be a wealth of information - narrating the process of interventions,
efforts put in, results and impacts.
Consolidation of reports at different levels provides information to make action
plans and work out on budget allocation.
The impact of the work can be used as tools for designing training. It becomes the
source for research and advocacy.
Proper documentation at every level will help to run the programme smoothly. It
sets the pattern and it is easy for transition when the other person comes in or
takes over the work.
The quality of service can be measured.
Sometimes this information raises thought provoking issues.
The list of documents
Profile of the service user\case history\photographs
The details of identification, treatment and stability
List of dropouts and the reason for it.
Baseline data (to use as secondary data).
Photographs before and after stabilization.
Individual intervention plans with follow-up details.
Process documentation of the events.
All training reports (consisting 5 W and 1H).
Identification and Mapping of the organization.
Documenting the key learning at every stage of implementation (impacts, failures and
challenges).
Review and Action plans.
Evaluation report of the programme.
Reports on the activities of sustainable livelihoods.
Registers showing stock of medicines.
Report of the existing knowledge and practices of the community, which later can be used
as a base for research study.
Annual Reports
Records of the loans sanctioned.
Video presentations, clippings and other training materials.
Successful Life stories.
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Some challenges in documentation work are as follows:
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Time management
How to write or who has to document what?
How to use these documents at the field level?
What to document and what not to document?
Why we need to document?
Refer back to the advocacy and documentation chapter on individual file format
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Session 5
Documenting baseline: 45 minutes
1. Trainer brainstorm with the group on what is base line? and why base line?
2. Trainer writes down the responses on the black board and summarizes with the definition
of base line and its importance
3. Trainer divides the participants in to three groups and asks them to come out with a draft
format of areas of information required to be collected for base line
4. Trainer invites group to share their discussions
5. Trainer helps groups to arrive at the format for base line document.
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Session 5
Base line format:
Text of Baseline Information
1. Review of Literature
A. Policy - Mental Health Policy 2002 (Government of India)
- similar Policy at State Level (if available)
B. Legislation
Mental Health Act 1982
PWD Act
RCI act
DMHP
(Who is responsible for implementation) State Government - Key People
- Ministers/State secretaries
- Government Departments
- Disability commissioners
- State level Co-ordination committees
- Task forces
- Any other state level committees
- Local MLA/MLC
District Level - Key people
- District Commissioners
- Chief executive officers
- Chief secretaries for zilla panchayat
- Dt. rehabilitation officer
- Asst dir. For women and child development
- Dt.Health officer
- Line department heads
- Corporation heads
- Special boards
- Judicial /police heads
- Any others
Taluk Level Officials
Gram panchayat Level
Panchayats, local MLAs and MLCs, MP
C. Schemes
a) SGSY
b) J RY
c) PMRY
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d) ICDS
e) JANMABHOOMI
f) ADHARA and ASHRAYA
g) GANGA KALYAN YOJNA
h) SC8T BC CORPORATION
i) PENSION
j) RATION CARD
k) ID CARD
l) LIONS and ROTARY CLUBS
m) VOLUNTARY NGO SCHEMES
n) WOMENS DEVELOPMENT CORPORATION
o) DRDA
p) ANTHYOAYA
D. Research Studies/Documents Published by Government / Related NGOs /
Academic Bodies / Institutions) on the subject
Project area maps / Govt. Administration maps
2. HEALTH RESOURCES - Review of Existing General Health and Mental Health Services
in the Area of Operation in relation to population
Population
No of Psychiatrists/Clinical Psychologists/Psychiatric Social Workers/Nurses trained in
psychiatry in the area (Give ratio per lakh population)
No. of Govt. Psychiatric Hospitals (No. of posts vs No. present)
No. of Pvt. Psychiatric Hospitals
No. of General Hospitals (Govt, and Private) (Give Bed strength, No of posts available
and filled), Dt Hospitals, PHC, PHUs, peripheral centers, Health workers
No of General Physicians /Nurses/Dentists per lakh population
Note: Details such as distance from the area / transport facilities and frequency of visits of
the personnel are important)
Traditional Healing methods operating in the area
Alternative Indian Medical Services - Homeopathy, Ayurveda, Others
3. Education resources - Schools, facilities for disabled, Hostels, NGOs, Ashrams
4. Socio Economic Condition of the people
Indicators:
Per capita income
Persons below the poverty line
General literacy rate and female literacy rate
% of girls in school
Human Development Index in relation to Indian avg.
Human Poverty Index in relation to Indian avg.
Housing Conditions in the area
Roads,
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Communication - post office, telephones, computers, email facilities, fax
Water
Electricity
Drainage
Occupation and income levels
Livelihood options
Trade Analysis
Religious and culture practices
Customs/myths/traditions
4. NETWORKS IN THE PROJECT AREA
Review of all other services and the administrative links
Government Departments, Schemes and Programmes to benefit the poor
NGOs / Private and Corporate programmes for the poor operating in the area
Government Schemes (with brief information about each, also if any people with mental
illness have accessed and benefited from these)
Sanghas
Youth clubs
Co-operatives
Committees
Associations
Informal panchayats
Community Leaders
5. Review of the situation of Persons with Mental Illness
- No identified
- Issues/problems faced by them
- Their needs
- Practices in the family-religious, cultural, Human rights abuses, neglect,
overprotection
- Awareness and attitudes
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Session 6
Alliance Building: 30 minutes
1. Trainer invites participants to brainstorm on the various stake holders in the community
and their participation.
2. Trainer lists down the responses in the black board.
3. Trainer would write the web and put all the responses in the web, keeping people with
mental illness in the center and linking all the stakeholders in the web.
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Session 6
Networking and Alliance Building
“Coming together is a beginning; keeping together is progress; working together is
success.”
— Henry Ford
In the NGO world there is constant talk about networking and alliance building. This is
especially true in the area of advocacy. To create positive change in our communities, in society
and even in our workplaces, organisations and individuals need to come together to collaborate
and achieve common goals. The result of this coming together and collaboration has been
called a variety of terms - alliances, coalitions and networks.
What are Networks?
Networks consist of individuals or organisations that share information, ideas and resources to
accomplish individual or group goals. Networking is a process of acquiring resources and
building power by using or creating linkages between two or more individuals, groups or
organisataions. Networks tend to be loose, flexible associations of people and groups brought
together by a common interest or concern to share information and ideas. Networking is about
seeking multilateral co-operation with other persons or organisations. Some reasons for
networking :
• Dissemination of information
• Dissemination of know-how
• Coordination of activities in terms of synergy
• Capacity building of members
• Technical guidance and coordination
• Seek social well being and social progress
• Make use of partners’ skills and resources and seek more specialisation
• Stimulate competition in terms of bringing together resources
What are Alliances?
Alliances are groups of people or organisations working together to pursue a single goal or a
specific objective. Alliances tend to have a more formalised structure, and their permanence
can give clout and leverage.
Alliances may be local, regional, national or international. Some may be formed to achieve one
short term objective. The alliance is dissolved when the issue has been solved or the event has
been coordinated. While other that focus on more than one but related issues such as nutrition
and health, population and environment, etc., will be more permanent in nature and recognize
the value of mobilizing together for action over a long time.
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In terms of structure, some alliances may be formally organised and highly structured, while
others more informal and flexible, relying on volunteers. Alliances are seen as perfect vehicle
for NGO collaboration. Alliances are usually strongest if they grow organically out of common
interests and unlikely to survive if they are externally imposed.
Working through alliances has many benefits :
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Increased access to decision makers and other contacts
Improved credibility and visibility
Opportunities to broaden public support
Opportunity to strengthen civil society on the whole
Different NGOs have different areas of expertise,, varied resources and attract different
stakeholders. Building a diverse alliance increases one’s chances of success and proves to the
decision makers in power that there is a broad social support for the desired policy change.
Decision makers are also more likely to pay attention to alliances, as they bring a stronger voice
to the decision making table.
Alliances Checklist:
•
Membership: Who do you want to work with? What criteria for joining the alliance? A
clear statement of principles that defines the purpose, mission, goals and benefits of
membership.
•
Commitment: What are the expectations of the members? Where, when and how does
the alliance meet? How to keep the members informed, involved and motivated.
•
Decision Making: How will the decision making works? The process must address
principles of equality and democracy and include opportunities for group discussions,
procedures for conflict resolution, methods for delegating tasks and a scheduled rotation
of leadership responsibilities.
Communication: How will members communicate, exchange ideas and information
quickly and efficiently? There must be a commitment to attend meetings and events.
Records of all meetings, decisions and actron taken to be organised and available to
members. There should be commonly accepted spokespersons for the alliance and a
communication plan for crisis situations.
Alliance Building in Mental health Sector
While trying to understand the process of Alliance Building, it will be valuable to ask the following
questions:
•
•
What is the nature of alliance one has built around one’s work in the mental health
sector?
How did it emerge?
206
•
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What is its relevance?
Who are the players in it currently?
Can/should there be others one can think of?
Where does Alliance Building lead to?
In reflecting the above, we may discover that alliance building occurs as a result of shared belief
and vision that aspirations of persons with mental illness will be fulfilled, their rights respected
and that they live a life of dignity.
Members in the Alliance Building function out of an extreme sense of responsibility,
accountability, have respect for each other and their autonomy, and exhibit transparency in
action. Alliance Building does not merely arise out of given situation or roles. It is a conviction
one develops while engaging with poor and most disadvantaged. With humility one recognizes
that affected people themselves exhibit great courage and stamina living against all odds. The
enormity of issues faced demands that a large enough force to be created - an alliance in a
spirit of collaborating and cooperation.
Alliance Building is organic in nature in the context of institutionalization and relates to
sustainability of change and people taking responsibility themselves. It is based on the belief
that bringing various stakeholders in mental health scenario engaged in short term actions to
integrate into long term development processes of strategic planning is crucial. And there is a
need to look at the possibility of its replication. Issues of policies and stakeholders remain the
focus of Alliance Building.
Various stake holders in the community
•
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Service users as those people who have mental health issues and are using the services.
Caregivers and field staff
8HG members
Local group leaders like Panchayats leaders
Local resource organizations
Government bodies like:
- Health sector - PHC, Government Hospitals, Taluk and District health centres
Panchayats Raj,
- Education - Anganwadi workers, teachers, SDMC members, etc.
- Law and Order - Police
- Social Welfare - Department of Disabled welfare, Department of women and
children
Traditional healers as alternative source of medicine
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Religious institutions
Donor agencies
Media
Hospitals - private and government practitioners, Psychiatrist, Nurses
Trained Community Counselors
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•
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Women groups, youth groups, farmers groups and so on
Volunteers and students from community
Industries and Corporate sector - which is socially responsible, to sustain the project
Influence makers
Friends of the movements — Ayurveda, Siddha medicines, and other alternative medicines
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Session 7
Work ethics - 120 minutes
Ethics and life principles: (35 min.)
Activity 1:
• Trainer shares the following principles:
Ten Principles
1. God exists and loves us.
2. When I make a mistake, admit it out loud.
3. People, including me, are basically good and want to do the right thing.
4. Speak and do what is right calmly.
5. Consider the effects of present actions on the 10th generation.
6. Lead by example. Be the first to do what is right.
7. Do the words I tell others to do.
8. Let tears out.
9. Be equally kind to strangers, family and friends.
10. Say 'no' and 'yes' firmly.
•
Participants will list 2 principles in their life that they never compromise on, starting with
the trainer.
•
Trainer brings to the light of the participants that’s life principles basically revolves around
them and not something that they impose on others.
•
Trainer asks participants to brainstorm on the word “Ethics”. Lists out their opinions and
then writes down the given definition. (Ethics are considered the moral standards by
which people judge behavior)
•
Participants to share one incident from work (Trainer insists that no names to be
mentioned) where they have expected people to have their life principles and judged
them as right or wrong. (Trainer shares this example where he/she overheard a bus
conversation of a young girl talking about boys and how he/she felt that the girl was bad
in character)
•
Trainer questions participants if they have a right to judge another persons action without
knowing the full background.
Ethics & Emotions: (35 min.)
Activity 2:
•
Trainer asks for 5 volunteers from the group for a small role-play. (Trainer does not reveal
the story until he gets 5 volunteers) (One plays the role of a counselor, another plays the
209
•
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role of a mentally ill woman who abuses her spouse as she is suspicious feels husband
is having an extra marital affair, the others play the role of a field staff taking the person to
visit the counselor) 5 min enactment time.
Trainer checks with the group is it necessary to take prior consent before any
conversation and is it important- as it makes people more involved and less
uncomfortable. Also linking it with the right to know what they are getting into.
Trainer also sights the example from the field where people sometimes are taken granted,
decision are made on their behalf, denial of property rights, enjoying property by the
siblings, not taking interest in the treatment process, mixing medicines for a PWMI into
their food without their consent, chaining them, locking them etc. Asks participants if they
would like that themselves. (If participants share the reason of interest in individuals well
being, trainer asks whose well-being? PWMI or care-giver as it makes life simpler for the
care-giver)
Now the trainer asks the volunteers to share any discomfort they felt in enacting the roles,
especially the PWMI (actor).
Trainer asks the following questions:
1. Did you feel comfortable sharing your personal life and issues in front of the field
staff?
2. What would you imagine they would do after listening to your story of abusing your
spouse?
3. How would you role play this scene differently?
Trainer then talks about privacy and non-judgmental attitude towards clients and their
own colleagues.
Empathy: (35 min.)
Activity 3:
•
•
•
•
•
•
•
Trainer asks participants to remove their footwear and leave it in one corner of a room,
he/she then asks participants to go and wear a pair that does not belong to them.
The trainer explains that empathy in-short means that they put themselves in another
persons shoes, meaning looking at it from their angle, feeling their emotions, etc
The trainer then asks the participants if they have honestly ever felt like they themselves
in place of a PWMI. If yes, how?
Trainer explains that empathy helps you understand the individual’s feelings and helps
you be non-judgmental.
Trainer calls back the volunteers who played the role of field staff and counselor and asks
them if while playing their role, they looked at the PWMI (character) without judgment
when they explained that they were abusing their spouse, other examples given in the
previous exercise. If they say yes, ask how?
Trainer then explains that when we empathize we also maintain confidentiality.
Trainer then refers to the issue confidentiality - explaining that it is disturbing for any
individual to know that the incidents in their life is being discussed by people who say they
want to help them.
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•
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Trainer then explains that the above qualities help to build confidence in people, both on
themselves and on those around them.
Trainer also explains that these also contribute to help a person in overcoming the illness.
Trainer then asks for reflections from the field from the participants.
Professional Ethics - A Recap: (15 min)
Trainer asks the participants to list what ethics were not followed in the following story:
Shivanna is a 25 year old man. he has been suffering from schizophrenia for 5 long years.
He never really liked to go for the treatment and counseling sessions that were arranged by a
local social worker who was part of an NGO. He also did not want to take the bitter medicines
that were given to here. He was motivated to meet the doctor, got convinced to take
medicines for few days. Later family strated mixing medicines in the food, his symptoms got
reduced and got stabalised, started involving in agricultural activities.
A few weeks ago, when the social worker visited their village he heard about his
engagement. The social worker visited the family to find out about the shivanna. Family
informed him about his wedding, said that he is recovered now, does not want to take
medicines in future. Social worker was said not to visit them after marriage has his wife
would come to know about the illness. Parents were happy that his son was getting married,
the responsibility of caring would be shifted to his wife.
Social worker asked the family, has they informed about his illness to the spouse (future
wife). Social worker asked many questions including his ability to manage life, wife and
sexual abilities, Shivanna was hearing this conversation, he was nervous. Shivann was
uncomfortable as the social worker asked many personal questions when people around him
are watching and listening. He could see, other people were already whispering among
themselves, he felt ashamed, embarrassed and low.
Hints:
1. Name of individual mentioned
2. Medicine and Counseling compelled without consent
3. No Privacy
4. No confidentiality
5. Judgmental attitude
6. Empathy not found.
Trainer wraps up by asking participants to look at their own work experiences and write a small
essay to themselves on the above ethics and keep it for personal reflection.
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Session 7
General overview on Ethics:
Ethics often refers to moral values that govern the appropriate conduct of an individual or group.
It speaks to us as to how we ought to live, how we treat others and how we ought to run and
manage our own lives .It helps people differentiate between unacceptable and acceptable
behavior, between just and unjust. People learn ethical norms from home, school, and in social
settings as they grow up. However, each individual has a different interpretation of these norms
based on their individual experiences. To sum up, ethics can be defines as rules for
distinguishing between what is morally right and wrong, what is responsible and irresponsible
and what is good or bad in general.
Most people think they understand morality and ethics. For instance, if you ask a common
person to define morals and ethical behavior, they will most likely define these terms as being
right and good versus being evil and bad. When asked for further details of these definitions, the
common man is typically unable to specify exactly WHAT is good, right, moral, and ethical.
However, this will most likely result in a discussion of examples of both ethical and unethical
behavior without specifically defining these terms.
Since each person is raised differently with very diverse experiences, each person has a unique
definition of morality and ethical beliefs." Additionally, since society is continuously changing
their viewpoints and technological capabilities, ethics and morality are also changing
accordingly, even if organizations such as religions try to make people believe that morality is
constant. Basically, society changes whether we want it to or not. This is further proof that ethics
and morality are and will always be imprecise, thus not truly definable.
Yet, the common man still believes that they understand morality. Even those people who think
they are very ethical are actually deceiving themselves, because no one can truly know what
ethical really is. Thus, they can not possibly be ethical, at least in everyone's opinions.
Alternative ways to describe ethics include:
Ethics is two things. First, ethics refers to well based standards of right and wrong that prescribe
what humans ought to do, usually in terms of rights, obligations, benefits to society, fairness, or
specific virtues. Ethics, for example, refers to those standards that impose the reasonable
obligations to refrain from rape, stealing, murder, assault, slander, and fraud. Ethical standards
also include those that enjoin virtues of honesty, compassion, and loyalty. And, ethical standards
include standards relating to rights, such as the right to life, the right to freedom from injury, and
the right to privacy. Such standards are adequate standards of ethics because they are
supported by consistent and well founded reasons.
Secondly, ethics refers to the study and development of one's ethical standards. As mentioned
above, feelings, laws, and social norms can deviate from what is ethical. So it is necessary to
212
constantly examine one's standards to ensure that they are reasonable and well-founded. Ethics
also means, then, the continuous effort of studying our own moral beliefs and our moral conduct,
and striving to ensure that we, and the institutions we help to shape, live up to standards that are
reasonable and solidly-based.
Code of ethics for social workers/field staff
1. A social worker or social service worker shall maintain the best interest of the client as the
primary professional obligation;
2. A social worker or social service worker shall respect the intrinsic worth of the persons
she or he serves in her or his professional relationships with them;
3. A social worker or social service worker shall carry out her or his professional duties and
obligations with integrity and objectivity;
4. A social worker or social service worker shall have and maintain competence in the
provision of a social work or social service work service to a client;
5. A social worker or social service worker shall not exploit the relationship with a client for
personal benefit, gain or gratification;
6. A social worker or social service worker shall protect the confidentiality of all
professionally acquired information. He or she shall disclose such information only when
required or allowed by law to do so, or when clients have consented to disclosure;
7. A social worker or social service worker who engages in another profession, occupation,
affiliation or calling shall not allow these outside interests to affect the social work or
social service work relationship with the client;
8. A social worker or social service worker shall not provide social work or social service
work services in a manner that discredits the profession of social work or social service
work or diminishes the public’s trust in either profession;
9. A social worker or social service worker shall promote excellence in his or her respective
profession;
10. A social worker or social service worker shall advocate change in the best interest of the
client, and for the overall benefit of society, the environment and the global community.
Professional Ethics:
The daily work of social worker poses distinct ethical challenges. Mental illnesses directly affect
thoughts, feelings, intentions, behaviors, and relationships - those attributes that help define
people as individuals and as persons. The therapeutic alliance between psychiatric social worker
and patients struggling with mental illness thus has a special ethical nature. Moreover, because
of their unique clinical expertise, social workers are entrusted with a heightened professional
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obligation: to prevent patients from causing harm to themselves or others. Social worker may
consequently be required to treat people against their wishes and breach the usual expectations
of confidentiality. These features of psychiatric practice may therefore create greater asymmetry
in interpersonal power than in other professional relationships and introduce ethical issues of
broad social relevance. For all these reasons, social worker are called upon to be especially
attentive to the ethical aspects of their work and to act with great professionalism.
7. Social worker -patient relationship
It is at the heart of psychiatric practice. Many ethical principles have bearing on this relationship,
including respect for persons, beneficence, autonomy, honesty, confidentiality, and fidelity.
2. Professional competence
From an ethical perspective, it is expected that social worker will maintain a sufficient level of
professional competence through continuing education, supervision, consultation, or study. It is
further expected that social worker will make referrals or delegate care only to persons who are
competent to deliver the necessary treatment.
3. Confidentiality
Confidentiality is the obligation not to reveal a patient’s personal information without his or her
explicit permission. It is important to distinguish between the ethical duty to keep confidences
(an obligation created by and owed to the patient) from the legal duty that governs the handling
of private medical information (an obligation created by the state). Respecting patients’
confidentiality is especially important for social workers because patients entrust them with
highly personal and often sensitive information. Patients’ willingness to make painful,
stigmatizing, or embarrassing disclosures depends on their trust in the social worker and its
expectation of confidentiality. Beyond this therapeutic rationale, there are ethical duties that arise
from principles of promise-keeping, doing good, seeking benefits, and avoiding harm.
4 .Honesty and Trust
Honesty and trust are elemental values of a profession. Honesty entails the “positive” duty to tell
the truth as well as the “negative” duty not to lie or intentionally mislead someone. Derived from
core principles of trustworthiness, integrity, and respect for persons, honesty and trust are
fundamental expectations for the patient seeking psychiatric care.
Social worker may be occasionally tempted to skirt or “soften” the truth in order to avoid harm to
a patient. In general, omission (intentional failure to disclose) and evasion (avoidance of telling
the truth) will undermine a trusting and constructive relationship between social worker and
patient and is not appropriate. Such behavior undermines trust in the profession as a whole and
in third-party interactions in particular. At the same time, out of respect for patient privacy, social
worker should reveal only the minimum information necessary during the third party review.
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5. Informed Consent
Informed consent is an ethically and legally important process that involves information-sharing
(e.g., about the nature of an illness and a recommended treatment) and knowledgeable and
authentic decision-making about the individual’s health (e.g., by a patient or authorized
surrogate). Informed consent for assessment or treatment is obtained if adequate information is
disclosed, the patient is capable to make a decision, and does so voluntarily.
6. Therapeutic Boundary-keeping
Boundaries may be described as defining the limits of a profession. There is necessary for a
professional distance and respect that ensure an atmosphere of safety and predictability.
Appropriate therapeutic boundaries are also necessary for therapeutic efficacy. Social workers
are trained to examine and appreciate the significant psychological and social overtones of the
treatment relationship. Their expertise consequently gives rise to specific rules that govern the
bounds of ethical practice.
They must never exploit or otherwise take advantage of patients. The unique position of power
afforded by the therapeutic relationship can be used in ways that are unrelated to treatment. The
social worker must therefore limit the relationship with patients to the therapeutic context. This
boundary requires that they avoid client interactions that are aimed at gratifying the physician's
needs and impulses.
7. Relations with the team
The primary goal in the development/CBR programme is to provide highest standard of care.
This derives from recognizable ethical standards of beneficence and fidelity to patients, and
draws on the expertise and ethics of professionals who are similarly devoted to mental health.
When social workers assume a collaborative role with other mental health clinicians, however,
they must assure that they are fully engaged and not merely used as “figure heads”. Decision
making in collaborative treatment approaches must occur in a manner that enhances the care of
the patient.
8. Responding to the unethical conduct of colleagues
All have an obligation to recognize and report the unethical behavior of colleagues. Unethical
conduct includes a variety of behaviors that violate professional standards. These may include
exploitation of a patient, dishonesty, fraud, or behavior meant to demean or humiliate others.
The duty to report unethical conduct is an essential part of a profession’s self-regulation. It is the
members of a profession who are in the best position to recognize unethical behavior from their
colleagues. The unethical practices not only harm patients, but also damage the programme as
a whole. Irrespective of the reasons behind misconduct, however, social worker have ethical
obligations to learn and follow their profession’s standards.
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9. Ethical issues in small communities
Small communities pose special ethical challenges to social worker because of the
interdependence of the members in the community. Many small communities face great
limitations of health care resources, and heightened barriers to care arising from weather,
geography, or lack of transportation. Social workers who serve small communities treat patients
who may be long-time neighbors, members of their extended family, local officials, or civic
leaders. Consequently, the ethical standard of separating personal and professional
relationships may be difficult to achieve.
Social worker in small communities may experience greater difficulty in protecting the health
information of their patients. When patients describe their own health-related experiences, they
may indirectly disclose information about family or community members who may be well-known
to them. The consequences of confidentiality breaches may be serious and enduring, particularly
given the stigma associated with mental illness. Certain communities may also require sensitivity
to cultural practices that are unique to the group. Practices, rituals, and conceptualizations of
fundamental medical principles (e.g., familial rather than individual consent) may require social
worker to obtain consultation or education on their role in these interactions. Respecting values
that may be prioritized differently can be useful in improving the relationship with the patient as
well as the entire community.
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Session 8: Reviews and evaluations: 30 minutes
1. Trainer asks the participants to brainstorm on why review or evaluation and how it helps
us in developing programme.
2. Trainer shares about the need for quarterly review to understand the problems at the field
level and how it can be addressed
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Chapter 8
Exposure visit
Exposure visit: will be planned for 2 days for the trainees so that they can observe the
community mental health and development activities.
Objectives: The trainees will be enabled to
1.
Experience the community mental health and development model as is
implemented in the field and interact with various stakeholders in the process
2. Gain an insight in to a variety of perspectives dictating field realities like gender,
poverty, family dynamics, community participation, community mobilization.
3. Understand the activities of community groups like Self Help Groups, Organisation of
Persons with Disabilities and discuss their work, with specific reference to Community
Mental Health and Development model.
The field visit:
•
The trainer and participants reach the project area of the Host NGO. The head of the
host NGO and staff make a presentation about their work.
•
The trainer divides the participants into three groups and assigns each group to a
resource person from the host NGO who takes his/her group to a particular village.
•
In the village, each group interacts with one Community Group and visits homes of two
persons with mental illness (preferably one male and one female) accessing services of
the community based mental health and development project.
•
The participants have :
> Brief space for sharing, asking questions and clarifications.
> Additional information where necessary.
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Day one: activities
Introduction of the participants and the organization
1.
Experience sharing from the project director and the coordinators
2.
Interaction with the field staff and the trainees
3.
Two home visits to people with mental illness (one male and one female)
4.
Interaction with the SHG members and their livelihood interventions for people with
5.
mental illness.
6.
Debriefing with the team
7.
Street theater
Day 2 activities:
1. Interaction with the federation members understanding advocacy efforts of the group.
2. Awareness programme (community group meetings
3. Consultation meeting
4. Caregivers meeting
5. Interaction with the volunteers
6. Debriefing with the group
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Chapter 9
FIELD SUPPORT
What is field support?
The trainer would visit the programme and support the field staff in initiating community mental
health and development activities. After gaining theoretical knowledge on community mental
health and development model, the field support will be exposed to community mental health
and development programme (where the programme been implemented). The trainer would visit
the field of the partner organization, would support them in initiating and reviewing the
community mental health and development activities.
What are the guide lines for the field support?
Basic guide line for the field support
1. Need for consulting person with mental illness.
2. Respecting and recognition of the rights of people with mental illness and treat them with
dignity.
3. How ever ill/poor the person, he or she has the capacity to manage his or her life.
4. Voices of people with mental illness should guide the programme.
5. Inclusion of people with mental illness in the development processes.
6. Inclusion of people with mental illness in the existing self help groups and federations.
7. People with mental illness and their supporters should be encourage and able to
advocate with the authorities for meeting their needs.
8. Mental health is a development issue, it need to included in all the development activities
of the organizations
9. Need for active participation of community in creating/designing a caring accommodative
and understanding environment to ensure fair treatment to People with mental illness in
the community.
10. Beyond meeting the treatment needs of people with mental illness, they also have a
variety of psychosocial needs, same need to be addressed using non pharmacological
approaches
What will be the field support?
The field staff should establish rapport with people with mental illness, gain their confidence and
build positive environment so the voices of people with mental illness are more heard and
respected. Field staff should be sensitive to the needs of people with mental illness, should have
open attitudes and unlearn themselves in terms of their own attitudes on mental illness. Field
staffs need to be oriented on why community mental health, how it would support their main
activity, how it will be included in their development work, what are the community mental health
and development activities.
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How field support will be provide?
The field support/on job training for the field staff need to be provided for 2 days once in four
months to the partner organization. The trainer would visit the field of the partner organization
and would provide on job training. The trainer spends one day in the field in facilitating and
observing community mental health and development activities. 2nd day will be spent with whole
team, in providing inputs and understanding difficulties experienced by the field staff in their
work, supporting them in identifying the alternatives for dealing with their difficulties.
Some of the support areas in the field are:
1. Demonstrating/conducting consultation
2. Demonstrating animations skills
3. Observing their awareness programmes and giving inputs for improving
4. Supporting difficult families and help them to understand the need to mental health care
5. Differentiation of mental illness and mental retardation
6. Understanding violent behavior, warning signs of violent behaviour
7. Demonstrating respect to people with mental illness and encouraging their voices
8. Similarities and difference of community mental health and development activities and the
community based rehabilitation activities
9. How to interact with PWMI and the families
10. Understanding individual and family needs to motivate the individual and family for
treatment, joining support groups etc
11. Understanding family dynamics to motivate, neglected and difficult families
12. Assessment of the individual with mental illness
13. Addressing misconceptions within the family
14. Organizing and facilitating caregivers groups
15. Organizing and facilitating community meetings towards mobilizing community support
16. Orienting community groups on mental health issues
17. Reviewing the documentation
18. Meeting the concerned government officials in sensitize them on the needs of people with
mental illness
19. Setting us of short term/ medium/long term plans with people with mental illness and their
families
20. Demonstration of trade analysis
Some of the areas for the theoretical in puts at the field level based on the field observations:
1. Assessment of people with mental illness.
2. Discussion on the misconceptions of people in the community and how same can
address.
3. Need for individual rehabilitation plan for each identified person with mental illness.
4. Documenting individual files and other programme reports.
5. Bare foot counseling/helping skills.
6. Facilitating discussion on why consultation and animation.
7. Helping the field staff to create/use the awareness materials.
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8. Differentiation of mental illness and mental retardation.
9. Discussion on needs of the family members and also people with mental illness based on
the field visits.
10. Facilitating discussion on trade analysis and local market and livelihood options.
11. Facilitating discussion with the partner organization on the need for Inclusion and
networking with other groups.
12. Facilitating discussion on need for engaging with the concerned government personnel
for meeting their entitlements.
13. Sharing of the experiences and learning’s.
14. Orienting the organization heads and the board members on mental health issues.
15. Orienting field staff on district mental health programme and National Rural Health
mission.
16. Orienting field staff on community monitoring.
17. Dealing with emotions and stress management
18. Demonstrating relaxations exercise
19. Base line document and need for base line
20. Demonstrating documentation and help field staff in practicing
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Chapter 10
List of energisers:
1. Chat Show (introduction)
Get the group to pair off and take turns in being a chat show host and guest. The chat show host
has to find out 3 interesting facts about their guest. Switch the roles and repeat.
Bring everyone back to the big group and ask them to present briefly the 3 facts about their
guest to the group. Maybe go round the group randomly so people are less aware of their turn
coming up next and panicking about it.
Watch timing on this one as it has a tendency to go on too long if your group likes to chat too
much.
2. If I were a...
Ask each person to say what they would be and why, if they were a...
• A piece of fruit
• An historical figure
• A household object
• A cartoon character
• Any other off the wall group you can think of!
Some examples:
I would be a pineapple as I am exotic, sweet and zingy.
I would be a egg-beater as I like to stir things up.
I would be horseas I rush around like a crazy creature
3. The Pocket/Purse Game
Everyone selects one (optionally two) items from their pocket or purse that has some personal
significance to them. They introduce themselves and do show and tell for the selected item and
why it is important to them.
For e.g people may have a picture of their family or their driving license. They need to explain
why they have them in their wallet/hand-bag.
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4. Paper Airplane Game
Everyone makes a paper airplane and writes their name, something they like and dislike on it
(You may also want to add additional questions). On cue, everyone throws their airplane around
the room. If you find an airplane, pick it and keep throwing it for 1-2 minutes. At the end of that
time, everyone must have one paper airplane. This is the person they must find and introduce to
the group.
5. Seven Up game
Every one counts the number starting from one, when it come to 7 or multiplication of 7, number
ending with 7, they should clap, if they say the number than they are out of the game. Finally
their will be one winner of the game. Trainer also would participate in the game
6. Three in Common Game
Break the group into 3’s. Their objective is for each group to find 3 things they have in common.
But not normal things like age, sex or hair color. It must be three uncommon things. After letting
the groups converse for 10 - 15 minutes, they (as a group) must tell the rest of the groups the 3
things they have in common.
7. Circle of Friends Game
This is a great greeting and departure for a large group who will be attending a seminar for more
than one day together and the chances of meeting everyone in the room is almost impossible.
Form two large circles (or simply form two lines side by side), one inside the other and have the
people in the inside circle face the people in the outside circle. Ask the circles to take one step in
the opposite directions, allowing them to meet each new person as the circle continues to move
very slowly. If lines are formed, they simply keep the line moving very slowly, as they introduce
themselves.
8. Marooned Game
You are marooned on a island. What five (you can use a different number, such as seven,
depending upon the size of each team) items would you have brought with you if you knew there
was a chance that you might be stranded. Note that they are only allowed five items per team,
not per person. You can have them write their items on a flip chart and discuss and defend their
choices with the whole group. This activity helps them to learn about other's values and problem
solving styles and promotes teamwork.
9. Decision making
You are in the middle of the sea in a big boat, the big boat started drowning due to technical
problem. Along with you and your spouse, you have other co passengers like 17 year old
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disabled boy, 30 year old pregnant lady, 65 year old man and his wife 60 year old woman, 20
year old man. The boat was drowning, now only two people can escape by getting in to small
boat which carries two people. If given choice for you whom do you send in that small boat and
reason out why did you select them?, there is no right or wrong answer in this.
10 Story Time Game
The facilitator starts a story by saying a sentence. It then goes in a circle, each person adding a
sentence onto the story-after repeating each sentence that's already been added.
11. Ball Toss Game
This is a semi-review and wake-up exercise when covering material that requires heavy
concentration. Have everyone stand up and form a resemblance of a circle. It does not have to
be perfect, but they should all be facing in, looking at each other. Through the ball to a person
and have tell what they thought was the most important learning during the day. They then throw
to other person explaining what they though was the most important concept. Continue the
exercise until everyone has caught the ball at least once and explained an important concept of
the material just covered.
12. Observe the opposite person
The participants will be asked to divide in to two groups of equal number. One group would act
as observer and other group would be acting as statues. Both the groups would be asked to
stand in line facing each other. The observer group is given 2 minutes for seeing the person in
front of them. They are asked to go out of the room for 2 minutes. The statute group will be
asked to make some changes in them (eg like changing the watch from left to right side,
removing the buttons of the shirt, changing the hair style, changing the place of pen etc). The
observer group is called, they would stand in the line facing their partner, they are asked to tell
the changes in their partners.
13. Group untangle
The whole group of teens will assemble in a circle with each person clasping a hand of someone
different. (In other words, they will be holding one person’s hand with their left hand and
someone e/se’s with their right hand) IMPORTANT! It cannot be the person next to them.
Now that they are in a complete jumble, blow the whistle and give them one minute to get
untangled without letting go of each other’s hands.
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14. Rebel Foot
Ask group members to sit comfortably. Then ask them to lift their right feet off the floor and
make clockwise circles, while doing this, ask them to draw the number ‘6’ in the air with their
right hands. Their feet will change directions and there’s nothing they can do about it. As we
said, thinking controls behavior!
15. Blindfolded Animals
This activity can be used to separate people into pairs. With a small group, write the name of
however many animals on two different pieces of paper and have the participants draw one out.
With a large group, have students count off to a certain number and assign a certain animal for
each number. When you say “go”, participants will close their eyes and are only allowed to make
the noise of their animal in order to find their other group members. Animals such as cows, pigs,
dogs, chickens, elephants, cats, and horses all make for a fun, and noisy, activity.
16. Trees Up Here Good -
Group repeats the words and motions of the leader
Leader: “Trees up here good!” Jumps up and puts hands high above head. Others: Repeat
Leader: “Trees down here bad.” Squats down and puts hands on ground. Others: Repeat
Repeat this whole cycle 3 or 4 more times, then end on “Trees up here good.
17 Mixing the group with an exercise The group will be asked to sit comfortable on their chairs in a circle. Trainer will introduce the
game by saying those people wearing slippers need to change their seats, when said all the
participants wearing slippers should change, trainer would find his seat. The person who has not
found the seat will have to ask people to change their seats giving options like (those who are
wearing watches, those having money with them, those having gray hair etc)
18. Enactment what you did
Participants are given a doll asked them to pass it to the person sitting next to him, before
passing they are asked to do some thing to the doll. Once they complete, participants are asked
to repeat what they did to the doll to the person sitting next to them.
19. Joining together in Groups
The participants move about freely. The trainer calls out a number, for e.g. ‘three’ or ‘seven’. The
participants must immediately join together in groups corresponding to the number called out..
Those who are unable to join a group of the correct size are out of the game. The game
continues until only two participants remain.
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20. Knowing the names of all in the Group
Participants sit in a circle. The trainer asks one of them to start with his/her name. The next
person repeats the first one’s name and adds his/her own name. The participants go on until the
last person repeats all the names.
21. Statues
Participants form pairs. One partner is the clay. The other is the sculptor. The clay stands
entirely relaxed, while the sculptor arranges him/her in certain posture. Neither may speak
during the game. They then exchange roles. Sculptors may be left to choose the postures or the
trainer may specify what is to be depicted, e.g., ’fear’, ‘anger’, ‘joy’.
22. Follow the Leader
Participants assemble in a circle. One participant is asked to volunteer to go out. The Trainer
asks one to play the role of the leader. The leader performs an action which is followed by others
(e.g. clapping hands). The leader changes actions from time to time. The volunteer participant is
asked to come inside while the group is engaged in one action initiated by the leader.
Volunteer’s role is to identify the leader, who initiates /changes actions without being noticed .
When the volunteer identifies the leader, he/she goes out. A few rounds may be played.
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