An Exploration of Innovative Community Mental Health Programmes in India

Item

Title: An Exploration of Innovative
Community Mental Health Programmes in India
extracted text: An Exploration of Innovative
Community Mental Health Programmes in India
By

Dr. R.L. Kapur
Consultant
Community Health Cell,
No.367, Srinivasa Nilaya, Jakkasandra, I Main, I Block, Koramangala, Bangalore 560 034

Introduction:

1.

The term mental disorder covers a broad range of conditions which share in
common, an experience of psychological distress and social dysfunctioning
either by the affected person or the family or both. On one end there are diseases
which have a genetic origin and are accompanied by demonstrable, neuro
chemical imbalances or structural changes in the nervous system. On the other
end are syndromes, which reflect a breakdown of a vulnerable person tn response
to environmental pressures. The vulnerability may be due to an extremely
sensitive and reactive personality right from birth, or social inequity and
deprivation, often both. There are also conditions where the pathology is
primarily in the social sphere, enticing people from susceptible backgrounds into
anti-social behaviour. Because of a varied and complexly interrelated aetiological
factors, the treatment and prevention strategies as well as the role of the
community in these strategies are likely to be different. In some conditions the
role of a medically trained person will be more important. For others, social
agencies need to take a lead and for some others nothing short of a change in
socio-economic and political structuring of the society will do.

2.

On the biological end there are conditions like schizophrenia, manic-depressive
disorder and organic brain disorders, which have to be managed by appropriate
medication and social support. At least 2% of the population suffer from these
conditions at any given time. In spite of best efforts in the least of circumstances,
at least one third of the people affected by these conditions end up suffering a
chronic illness, unable to fend for themselves and needing to be protected.
What is required here is, (a) early recognition of the illness, (b) sensitization of
the community to the fact that such people need understanding rather than
punishment, (c) provision of necessary medical help, and finally, (d) provision of
a caring environment for the chronically ill.

A number of experiments have been conducted in India to target these conditions
(Kapur 1994). The most important experiments have been where the members of
a primary health centre team have been trained to recognize and manage these
illnesses in the community. In one such experiment (ICMR 1987) it was
discovered that while the PHC team can be taught to do this task very adequately

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in a research situation, the motivation, resources and morale required to carry out
the treatment in unsupervised PHCs falls short of the expected. Just to illustrate,
the cost of medication required to manage the psychotic population in a
community is more than the total budget for medication in a PHC. Further, in an
average PHC there are so many priority targets that mental health does not elicit
sufficient enthusiasm from the personnel. That good intentions and good training
programmes are not enough, was demonstrated by the poor outcome of the
National Mental Health Programme instituted in the 7th Plan (DGHS 1982 and
DGHS-WHO SEARO 1990).
One negative impact of an otherwise enlightened approach has been the attempt
of old mental institutions to discharge chronic patients into the community
because they have been shown to fare better within the family (Pai and Kapur
1982, 1983).

What is not realized is the fact that because of increasing migration to the cities,
gradual diminution of family size and fewer people available at home to look after
the chronically ill, families are unable rather than unwilling to carry out this task.
Many chronic patients sent back to their families remain neglected. That more
residential places for the chronically ill are needed is demonstrated by the fact that
for 250-300 places available in the private hostels, rehabilitation centres etc., there
are long waiting lists in spite of prohibitive costs.
Notwithstanding the above, individuals and organisations are continuing to
develop and establish programmes for the care of patients suffering from severe
mental morbidity. For example. NIMHANS, which evaluated the first such
programme, is now adopting districts where the GPs, also village leaders, are
taught to handle such problems ( Rao et al 1990). Programmes for educating the
public about mental health are also going on. There are also temples and
dharmashalas as well as modern rehabilitation centres across the country for the
care of the chronically ill. However the philosophy of these programmes as well
as the nature of service they offer is not sufficiently documented. Research is
needed to look into these aspects

3.

At least 8-10% of the population suffers from neuroses (anxiety, depression and
conversion reactions), psychosomatic illness, personality disorders and substance
abuse. It has been shown through research that at least one third of the clients,
who go to doctors in the PHCs or a private GP, suffer primarily from these
disorders (Wig et al 1981). Most of these patients require counselling and social
support to develop coping strategies, rather than medical help. Unfortunately the
doctors, not trained in consulting techniques offer tranquilizers which work only
temporarily and if used for a long time, lead to dependence and abuse.

There was a time when people in need of such help were looked after by faith
healers, priests and spiritual masters. Stories from folklore and mythology were
used to rouse a person to a meaningful existence in spite of trials and tribulations.

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There were clear-cut values to live by. Social change has diluted these values and
the stories which were effective before, now appear to be naive and irrelevant.
The situation is worse in urban slums where the alienation is even greater and
social support even less. But people still go to faith healers and spiritual masters.
The popularity of lectures on spiritual matters, yoga centres, Vedanta courses and
spiritual retreats is apparently on the increase. In addition, counselling centres
based on modern psychological techniques are also available. One hears of
transactional analysis, personality development courses, Reiki and Pranik
Healing. It is estimated that only in the city of Bangalore at least 5000 people
pass through these centres every year (Chopra 1994). In many cities there are
now centres for de-addiction based on a variety of specified or unspecified
strategies.
One does not know how these centres work; what are the philosophies and
strategies they use, what is their organisational structure, what are their success
stories, what difficulties they come across etc. Research is needed to examine
these aspects.

4.

Many psychological problems arise out of social deprivation, social inequities and
unhealthy power relationships in the society. The problems of battered women,
battered children, and suicides because of hopeless existence, are well known.
While this is an issue for the whole society to consider, special centres dealing
with such problems have also come up. Programmes are also available in
institutions, like schools and colleges as well as some jails, to deal with factors
which lead to anti -social behaviour. Once again, not much is known about how
these programmes are designed. Research is required to understand these
programmes.

5.

There are very significant changes occurring and anticipated in society because of
economic re-structuring which is going on in the country. Research has been
undertaken by some organisations, such as ISST in Delhi, to assess the social
consequences of these programmes. There is also lobbying, education and
political action being undertaken to counteract the ill effects of the programmes.
Research is needed to understand the impact of such programmes.

The proposed study:
(1)

Aims and Objectives: The overall aim of the study is to explore the innovative
mental health programmes in the country and to establish a network amongst
them so that the facilitators could learn from each other. More specifically the
inquiry will cover the following questions:
The scope and content of the programmes.
(a)
The nature of community involvement.
(b)
The effectiveness of the programmes.
(c)

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Methodology: The assessment will be carried out using the qualitative rather
than the quantitative approach, since the formalization required in the latter comes
in the way of obtaining rich information and thick descriptions. One is not yet at
a stage where specific hypothesis can be set up for examination.

The work will be first carried out in the city of Bangalore. First a directory will
be prepared of all such programmes, remembering that one is interested not only
in efforts by professional organisations but also by semi-professionals and non
professionals. Centres offering counselling of any nature (including spiritual
help) which aid in psychological well being will be looked at. This will be
followed by classifying the programmes in different categories (e g. programmes
for the acutely ill, programmes for the chronically disabled, suicide prevention,
lay counselling, spiritual counselling, counselling and advocacy for the deprived
etc.). Example from each category will then be chosen for further inquiry. This
inquiry will be carried out by the examination of (a) published literature by the
organisation (b) interviewing the staff members (c) sitting in on some of their
work sessions with their permission, and (d) interviewing the users who are
willing to talk. Where the last two are not possible, the staff will be encouraged
to tell their success stories. This will help in documenting the conceptual
framework in which they work. Attempt will also be made to find out through a
life history approach how those delivering the services got interested in the
pursuit.

There will be a constant give and take during these explorations. As one goes
along, the researchers will also keep giving suggestions from their own
experience regarding how these programmes could function even better. An
attempt will also be made to network these organisations by holding informal
meetings from time to time where representatives from these organisations could
get together.
This phase is expected to take 12-18 months. The design of the study will be
streamlined and used to carry out similar work elsewhere in the country.
Funding required:

1.

2.
3.
4.
5.

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Salaries of senior consultant and one research
assistant/ associate.
Funds for local travel.
Funds for stationary and secretarial help.
Funds for 3-4 meetings to evolve an informal
network of sharing & learning.
Funds for
(a) Directory
(b) Interim Report which will be circulated to all
those who participated and/or are interested.

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REFERENCES

Chopra, P. A Rising Market of Mind. IndiaToday. July 1994; Vol.19, No.14, 148-155.

D.G.H.S. National Mental Health Programme for India, 1982

D.G.H.S. National Mental Health Programme in Retrospect and Prospect. 1989;
D.G.H.S. New Delhi

D.G.H.S. National Mental Health Programme. A Progress Report (1982-90). 1990;
D G.H.S. and WHO-SEARO, New Delhi

I.C.M.R. Collaborative study of severe mental morbidity. Indian Council of Medical
Research and Department of Science and Technology, 1987.

Kapur, R.L. Community Involvement in mental Health Care, The National Medical
Journal Of India, 1994, Vol.7, No.6, 292-294.

Pai, S. and Kapur, R.L. (1982) . Impact of treatment intervention on the relationship
between dimensions of clinical psychopathology, social dysfunction and burden on the
family of psychiatric patient. Psychological Medicine, 12, 651-659.

Pai, S. and Kapur, R.L. (1983). Evaluaton of home care treatment for schizophrenic
patients. Acta Psychiatrica Scandinavica, 67, No.2, 80-88.
Rao, M., Chandrashekhar, C.R., Parthasarathy, R., Srinivas Murthy, R. Community
Participation in Mental Health Through Village Leaders: An Initial Observation. Swasth
Hind 1990; 34; 45-6.

Wig, N.N., Srinivas Murthy, R., Harding, T.W. A Model for Rural Psychiatric
Services: Raipur Rani Experience. Indian J Psychiatry. 1981; 23; 275-90.

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