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Community based services for people with
mental illness
Manual- community mental health and development for the
field staff
Basic Needs India
B.jsi s i c ■ N €||b d s I n cl i 3
...promoting mental health
and development
/
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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.
1 he field staff^ 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, tc
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 involvement of the trainees in the programmes,
meant for their own development. In short, these methods are participatory in nature.
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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________
Xhapter 6
documentation and advocacy
Chapter 7
Project management_________
Chapter 8
Exposure visit______________
Chapter 9
Field support_______________
Chapter 10
Energizers
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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?
in
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
impounded 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 meetsthe 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' 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
ommunity. 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.
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
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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 ir.
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.
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.
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How many days the training be organized?
1 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).
■^he 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.
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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
<v-
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
Topics to be covered
a. Dignity, recovery, prosperity, and self worth
b. Poverty and mental health
c. Sustainable Livelihoods
d. Trade analysis
e. Livelihood options
Capacity Building
The trainees should be able to:
1. Understand what is capacity building
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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
e. Organizing people with mental illness and caregivers in to self help groups/associations
f. Awareness generation
g. Gender
h. Mental health and development
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
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
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Topics to be covered
a. Strengths of development approach
b. rDocumentation 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.
•
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.
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•
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
o
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.
It is to be noted that the time indicated in the out line need not be binding on the trainer,
the user is free to structure the session differently, including variance in methodology.
Role of trainer:
The manual envisages a training process that focuses
teaching/delivering. The effective trainer is one who is:
on
learning
Also
rather than
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.
1.
2.
3.
4.
5.
6.
7.
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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 or.
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.
Reflection dairy:
1 rainer 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)
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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 the who the
person is?.
Trainer invites participants to express their thoughts on the same.
Expectations sharing : 20 minutes
•
•
•
•
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
•
Trainer suggests to the participants set the norms/ground rules for effective functioninc
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:
•
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.
o To provide a continuing commentary by participants on the life of the group.
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o 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
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 ove
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
f. Trainer summarizes the session, describing stress and its reactions
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.
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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.
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.
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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.
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 irole 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 menta'
illness.
8. Trainer summarizes the discussion with a triangle describing types of mental
illness and with its prevalence.
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.
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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.
2.
3.
4.
5.
Trainer shares about the objectives of National Mental health programme of 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.
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7. Prevention and promotional strategies:
60 minutes
Trainer invites participants to list out the causes of mental illness.
Trainer asks participants to reflect on the causes that can be prevented
Trainer asks participants to brainstorm on the promotional strategies for mental health.
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.
1.
2.
3.
4.
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.
9. Mental health and development model
60 minutes
1. Trainer divides participant in to three groups and ask them to list out the needs of
people with mental illness from their past experiences of knowing the person with
mental illness
2. Trainer invites the group to make presentation on the discussion
3. Trainer shares with them the needs expressed by people with mental illness in
past consultations through power point presentation/ chart papers
4. Trainer summarizes the discussion through presenting Mental Health and
Development Model of Basic Needs
5. Trainer shares about BNI partnership and its activities
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.
21
Ii
11. Why community mental health
60 minutes
1. Trainer invites participants to share their views on the prevalence of mental illness (what
2.
3.
4.
5.
6.
7.
8.
is the percentage of people with severe mental illness, common mental illness, epilepsy,
mental retardation)
Trainer provides information on prevalence of mental illness, project numbers for Indian
population
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)
Trainer provides information on the available mental health infrastructure against the projected
numbers of prevalence of mental illness for the country
Trainer invites the participants to share about the attitudes of the community on people with
mental illness
Trainer shares their experience of working with people with mental illness and how the quality of
life has changed after the intervention
Trainer makes presentation on the district mental health programme (Bellary model to 11th five
year plan)
Trainer invites participants to conclude the discussion by summarizing why community mental
health from the previous discussion
22
I J
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 anxiety, leading to decreased
performance.
•
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 chalienges/changes will help us come to terms with
problems
Stress is presented in the following forms of expression (voices):
• 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
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.
23
i i
Some common stressful situations:
• Change of residence
• Change of teacher
• Changing 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
Migration
New boss in the work place
Occupational stress
Onset of menarche
Rapid changes in physical
characteristics
Transfer from one city to another
The stress is manifested in various forms like
f ’n 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
Categories of stress:
stress”.eg JhangehtSchool^ewbosSMheoffireete
d° “
“mfortabte eg
mSlfe SS: e,
‘P°Sed ,0
"uallon fw
exposed
to “
difficult s
situation
for lon9er d“rati°" o'
eg unhappy
* marriage3'
‘
'aCin9 'he Sl,Ua"On as
"fes“ua,ion would lead,0
24
I i
Some ways to manage stress
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Adequate sleep and food intake to the
tired body
Become aware of stress inducing
occurrences by writing down events
that were stressful to you
Become aware of your stressors and
your emotional and physical and
behavioural reactions
Being positive - I can not face
challenges, say to ur self that I would
try my best and see if the challenges
can be successful faced.
Creative visualization
Deal with one thing at a time and
priorities your needs
Develop cooperation with others, not
competition, develop some mutual
supportive relationship
Distance from problem even if for a
short time
Do some things for others
Do some things just for yourself
Exercise and physical exercise- Hand
gripper, tennis ball
Follow good and healthy diet
Free time for your self
Good family and community support
Have a good laugh every day
Have some thing enjoyable
Identify the source of stress in your
life, list and priorities the source of
stress, Identify appropriate stress
management techniques, create your
stress management plans
Learn to delegate responsibilities
Learn to moderate your physical
reactions to stress
•
•
•
•
•
•
Listen to music and TV
Listen to what others are telling you:
people give their feed back saying you
are appearing tensed, restless
Make yourself available to others
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, racing heart,
eating out of control, have headaches
Plan recreation time and maintain
routines
Pursue realistic goals
Recognize what you can change/
reduce the intensity
Relaxation
Seek help if necessary
Share how you are feeling with some
one you can trust
Sit still for few minutes
Stop smoking
Systematic desensitization
Take at least few sips of water slowly divert mind
Take your mind off the context
Think about some thing pleasurable
which diverts your 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
Volunteer your service to others
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 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
25
diffieun t° accept the medical illness resulting disability, in such situation if we teach them how to
various typ^s of assocSonX^^^^
eXamine the
worries play an important role in the development of bodily illnesses. Some of these conditions
hat indi,?iHPtl? UC«’ hyPertens|On’ diabetes mellitus, rheumatoid arthritis. Studies have shown
t 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
seve7 uncomfortable bodily symptoms which include palpitation, sweating
°rs’ diyness of m°uth 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
ooay pans.
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
edness, lack of energy and disturbed sleep. Hypothyroidism often manifests with memory
...sturbances, 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 dea h may accompany illnesses like renal problems, heart problems, cancer etc. leading
to emotional disturbances.
26
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 a 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
27
i J
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.
28
1 1
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.
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.
Features (symptoms) of mental illnesses are broadly grouped as:
•
•
•
Disturbances in bodily functions
Changes in mental functions
Changes in personal and social activities
29
11
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
° g. person complaining of headache or body aches, same cannot be explained on the basis of known
.ysical 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-to-day 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
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; often-spurious sensations are also reported. Thus, even
without any external stimuli they perceive 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.
30
i 1
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 guality of life of family members.
31
I 1
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
ere are repeated unhappy experiences in childhood, they can contribute to development of
i nental 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
32
L J
Structural Model
Figure 4.1
The structural model of mental health
■I■■■■■■■■■
Social support
andotherinte.ctions
Societal structures
and resources
Mental
Health
Individual factors
Cultural values
33
11
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.
ase 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.
ase 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.
34
L i
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 anc
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.
35
11
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
'om home. We searched all over but did not find him. I think after more than two months his
orother 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
zpted 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.
36
11
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 oz
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
37
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Session 4 c
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
'll persons normal so that they lead a normal life. The following section deals with persons having major
lental 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
y Neglect of work and responsibilities
6) Social isolation
7) Thought disturbances
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.
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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
39
Session 4 b
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
mdividuals prefer to avoid facing these problems, ultimately resulting in a multiplicity of physical or
. sychological 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 Minor mental illness:
Depression: We all might have experienced feeling of unhappiness sometimes or the other and also
mtense grief following death of a close relative or a family member. But these feelings go off with time
nd usually do not require any treatment and also would not cause significant disturbances in the day-today 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 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.
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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.
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%.
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Session 5
Mental Retardation and Mental Illness: What's the Difference?
Mental Retardation
I 1. Mental retardation* refers to subaverage
intellectual functioning.
JI Mental retardation can be classified as profound,
I
severe, moderate, mild and borderline mental
retardation.
I
Mental Illness
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 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
liw!ng skills
h3. Mental
—retardation refers to impairment in social
adaptation.
I
4. National incidence: 3% of the general population
I
I
5. Mental retardation is present at birth or occurs
|| during the period of development.
ir6. In mental retardation, some degree of intellectual
2. Mental illness is an illness, if identified and
provide appropriate care services would recover
from illness and manage his/her life.
3. A person with a mental illness may be very
competent socially, but may have a character
disorder or other aberration.
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 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.
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.
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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. So 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 ii
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. Psychological 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.
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
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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
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
'•roup 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.
•
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.
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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.
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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 riqhts
violation.
M
5. Families may feel they are <contributing to the affected member’s problems, feel guilt and
would be more supportive. They1 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
o 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.
9. Families may experience severe stress, or marital discord or depression associated with
merrta7hh Tth '"h685’ reqUirin9 attention from the mental health professionals for their improving
46
11
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,
oisappointment 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 ana
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
f) Caregivers forum gives platform for them to raise their collective voices would help them for
advocating for their rights
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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?
We 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. Treatment for PWMI - support for the travel and medicines.
2. Dealing with negative symptoms.
3.
4.
5.
6.
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 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.
48
IJ
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.
49
I j
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
knowledge
general1 health care and social
. ®, ncourax9e application of mental health ---------■■■ oin
------------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
been ^mplemen^
haVe b660 taken UP 10 dlstricts where the district mental health programme has
> 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 10 five-year plan (2002-03 to 2006-07) and 1200 crores been
sanctioned in 11rn five year plan to implement DMHP prorgamme.
> Expansion of district mental health programme to all the districts in the 11
th five year plan.
The District Mental Health Programme (DMHP)
50
I i
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 2?
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 DMHP 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.
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 sector".
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.
51
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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
:are 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.
52
MM-TOO
I i
• 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.
•
53
i 1
______________ National Mental Health Programme- Budget Allocation
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
Research
50”
School Mental Health Programme
Nif
750
Nil
2230
Monitoring
150
NGOs
Nil
Nil
lotal
1900
11430
100
* “Manpower Development”
54
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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:
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
55
11
undZ^dwSti!Ute’ ^th fami!.y nOt able °r Willin9 t0 l00k after them- A not uncommon (though not
stood) factor is the contribution to mental illness of sexual exploitation within the family.
Individual level:
recognition of individuals ability to help themselves, given some critical supports.
Multi Dimensional Approach to Mental Health Promotion.
and prom°,ed h'Bas,c Needs india'we ses ,he
Policy and Program :
^dXasqAdewShni?<5dfi^flth 'S 3 .devel0Pmental issue and not just a medical problem. Hence it needs to be
for LonXS? n ?y’
Pohc,estand Pr°9rams- Within the health sectoral interventions, the potential
for contribution of the various systems of medicine/health, needs to be evaluated scientifically Where
assuVdPoPf its atalitv®7
encouraged’ 50 that Pe°P|e can choose the system they have faith in,
aoouicu ui iio quamy.
care and medications need to be accessible to needed individuals through the PHCs GPs
oluntary Sector agencies. This would require appropriate professional training interventions and
procurement and drtibuti0" of essential drugs. There Is ImpoAantly a need tor training aXakma
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.
generating solidarity
Provisiona
the 'Pe°P|e with Disability Act' need to be operationalized to benefit the
ental y ill persons and where needed additional welfare measures instituted. Mentally ill persons cannot
comWmin7t'v Livelihood
derived from being earninS and contributing members of the family and
impodan‘' ”th sohemes add,e5S,n9 ,heir spe“' "eeds'
There is need of educational campaigns to promote emotional wellness, at different walks of life One of
promotive programs, which also should include stigma reduction.
I
9
Jommunity Level:
Mentally ill persons and their caregivers need to be consulted and included in the community level
a vilfoqe? Sdf HefoGrounV’6^9'’0^^ °f °nly menta"y PerS°nS are Unlike,y to be Practical (to° few in
thinnfJi f’H?
T of dlsabled Persons (including mentally ill persons and caregivers) and which
coS?Xv mnortaJrn? ber rnarg.inahzed group could be the mechanism for inclusiveness. Such SHGs
could play important role in fostering solidarity and acceptance. At the same time awareness promotion
IddrA? mU “h-T meanstt0 address community level stigma is needed. There is need of a mechanism fo
address speedily exploitation and rights abuses, in the context of their vulnerability.
Family Support Structure:
Mentally ill persons in our experience get well within their family, as opposed to an institutional care
mPaPd°aCh'
thS farr"ly needs new insights, skills and emotional support themselves This is to be
foemse^^Wher^fomJ V'S'tS
C0Unseling
^unteers and SHG members who are trained
mselves. Where family caregivers are not available, other local support systems may be developed
56
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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)
57
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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
thf 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
o er 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
HannArh/iaaT'09 the impaCt °f lllneSS In the affected Person, their families and the society” (Mrazek &
f’ayycny, lyy^;.
nnhcipt3 ta neStS W'^
ysica!lllnesses and social problems stress the need for integrated public health
po icies targeting clusters of related problems, common determinants, early stages of multi problem
trajectories and populations at multiple risks.
prooiem
Effective prevention can reduce the risk of mental disorders
iSLintT wid®. rang® of evidence-based preventive programmes and policies available for
dArrlT«tntlOnh T?eSe b^6 been f0Und t0 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
58
Ii
benefits. These multi-outcome interventions illustrate that prevention can be cost-effective. 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
• Attention deficits
• Caring for chronically ill or
dementia patients
• Child abuse and neglect
• Chronic insomnia
• Chronic pain
• Communication deviance
• Displacement
• Early pregnancies
• Elder abuse
• Emotional
immaturity
and
dyscontrol
• Excessive substance use
• Exposure to aggression, violence
and trauma
or
• Family
conflict
family
disorganization
• Isolation and alienation
• Lack of education, transport,
housing
• Loneliness
• Low birth weight
• Low social class
Medical illness
Neighborhood dis organisation
Neuro chemical imbalance
Parental mental illness
Parental substance abuse
Peer rejection
Perinatal complications
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 disadvantage
Social incompetence
Stressful life events
Substance use during pregnancy
Unemployment
Urbanisation
Violence and delinquency
War
Work stress
59
l i
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
60
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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).
Rental 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.
61
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Finallv it is essential that efforts to promote mental health recognize and reflect the diversity of^cultures
goals - essentially a community development model.
In a sense this is no different from the process followed in most community-based health Promotion
pX » me pXs Is so similar, why set mental health promotion apart from generic health
promotion efforts?
Although the principles and processes may be similar, the outcomes of mental ^ealUi 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 hea th promotion f°cus®s
explicitly on mental health outcomes such as increased sense of personal control, empowermen ,
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's cl®%fro^'J?6,
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
ThVgoals 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.
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 hea'thy 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.
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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 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 (e.g. improving access to education, 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. 'Communities That Care' initiatives, integrated rural
development)
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Session 8
Mental health problems in children:
Its 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
oercentage 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:
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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
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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.
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.
I
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.
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Session 9
Mental health and development model
Mental health and development is an innovative model. Basic Needs India believes that how
ever poor of 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
I
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.
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.
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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.
j. 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.
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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 unigue situation and based on social
consensus'Xemohasis 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 pathbreaking 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.
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11
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.
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Session 11
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.
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Session 11 b
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 frorr
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 relapse. They often provide the first-line
treatment especially in situations where psychosocial interventions and highly skilled
professionals are unavailable.
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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
I
Communities, families and consumers should be included in the development and decision
making of policies, programmes and services. This should lead to services being better tailored
to peoples 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.
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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 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
hat 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
2. Ground realities
2.1 Demographic Characteristics
m
|
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
he age of 15 years is 32 % and the proportion of population above the age of 60 years is 8%.
i he 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.
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
76
i i
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”. 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.
77
i 1
2.5 Human Rights Violations
People lock or chain their kith and kin under pressure from others, due to helplessness and
f happ®ns du,e t0 the ignorance of family members and community in which they
i'^I0 if hCS'
2.6 Existing Laws
getting life partner for a boy or girl from that family is almost next to impossible because of the
st'gma, 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
m«ntaM|SUChfa pe.r®on- stl9ma 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
I
■
social exclusion, etc_ on mental illnesses are well known. It is also found that, people are not
nonfS HCCeT Care dUe t0Jhe!_r S0Cial conditions- And due to inadequate treatment, people with
abili/vt^wnrkTh remain dlsabled for longer and incur grater health care costs and lesser
ability to work, thus worsening poverty.
3. Infrastructure and Present Status
part of the credit goes to the intervention of the judiciary.
78
11
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, 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.
79
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Survey results of mental health facilities in India
SI.
No.
J_
2
3
4
7_
8
Facilities
Adequate
Number %
Infrastructure
12______
10
Clinical services including investigations 16
Availability of medicines and treatment 28
Staff
------------------
modalities____________
Quality of food
Availability of clothing and linen
Recreational facilities
Vocational rehabilitation facilities
23
15
18
14
32.4
27
43.2
75.7
Inadequate
Number %
25_____ 67,6
27
73
21_____
56.8
9
24.3
62.2 14
40.5 22
48.6 19
37.8 23
37.8
59.5
51.4
62.2
3.2 Mental Health professionals
this h^ll ece^ersd haveh^0
h?man reS°UrCe in mental health' The irony is that inspite of
s ser iH“nn9,p“pfe
Comparatively mental health professionals are more n fte
~„yfSaa,S S X
XSs;
Availability of mental health professionals in India
Number of psychiatrist per 100, 00Q population
jjumber 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
80
i J
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 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
81
^!?ee?hreCe>?tly established- 11 has t0 be noted that most of the NGOs have their setups and
tlets in the urban areas catering to the needs of middleclass and higher economic groupPs.
It is evident from the above reading that mental health
~
---------------- care in India is characterized bv
(i)
..................
Very limited mental health care facilities;
(ii)
Grossly inadequate professionals to provide mental health care(iii)
Famil esarethA^nrr^
U;gentuCare are 9etting any modern medical care;
(iv)
Families are the current care providers but with limited support and skills for care
(v)
No support schemes for voluntary organization;
(vi)
Lack of a regular mechanism for public mental health education(vii) I imi
fviiit
ad™in'sftratlve structure for monitoring the mental health’ programme and
( in) 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 objectives of the program are:
> To ensure availability and
— future.
> develLpmeT aPPliCati°n °f mental health knowledge in general health care and social
> 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
linkST °f baS'C Tental health care with general health services
Linkage to community
4.1.1 Progress of the NMHP
•
From the time of the formulation of the NMHP in Auaiic;t iqro in
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> 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 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.
83
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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 sector1.
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.
i he 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.
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
egislations, the World Mental Health Atlas 2005, reports that there is no Mental Health Policy in
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
■
are 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
84
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 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?
85
i /
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 Bv
4
R. Srinivasa Murthy.
’
y
4. Mental Health Atlas 2005, World health organization (WHO)
"T Q^l'ty Assurance in Mental Health, By National Human Rights Commission (NHRC)
t " e.^ d Hea,th Report 2001 ’ Mental Health: New Understanding, New Hope
Organization (2001b) Atlas: Mental Health Resources in the world
2001,WHO, Geneva
WHOOGenevalth Or9anization <2004a) The world health Report 2004: Changing history,
OToTwhS Geneva ani2a,iOn <2°°4b)
C°Unlry Res0l,rces for Neurological Disorders
I
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ii
Chapter 4
Capacity Building
87
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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?.
Session 1
. 'overty 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)
'elf 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
88
I i
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. Trainer invites the participants to share their views on recovery.
2. Trainer writes the responses in the black board.
3. Trainer summarizes the indicators of stabilization.
4. Trainer makes presentation on the definition of recovery.
5. 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.
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.
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.
89
Ii
3. Trainer invites group to presentation and categories the responses in the black board.
. Trainer summarizes the responses of the participants and links same to the self worth of
people with mental illness.
mfS0?/68' at!itudinal Prohiems in the community (including usus- .already
.already formed
formed opinion
opinion that
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
-i a oth
i
XXXlb’sS)5
ne bus, all women in one bus, all those
°n‘ bU8'
'n °,her bUS’ A"th0Se Wh° are
80 minutes
1' S“noteSbtohoekPa','CiPan'S ,0 Wr'te "’eir family inc°me (,rom a" s°urcas> f°r
month
2. Trainer asks the participants to list down the expenses for one week trainer oives
example like money spent for milk, flowers, groceries, fuel, fire wood for their travel etc
inCOme
4' s° thaHheJ"^at
3. weekly i'om:^1^"18 *
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 dav
9. Trainer asks participants to reflect on the expenses for the famHy functions (marriaoe
naming ceremony, death ceremony, puberty function, birthda? celeSon S How
ofUfhlIS hS relevant expenses’ ln comparison with the olden times?, How the relevance
funcTonsZ,0US
l0°Sin9? H°W Pe°ple are exhibitin9 ‘heir income in the family
What are the facilitating factors and what are the barriers (reasons for failures)
nounshment edu,:e“°n efc-MMns
90
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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 shoulc
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.
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)
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11
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.
Artide 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 damaqinq 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’.
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IJ
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 self-worth/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.
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SELF WORTH
I AM:
I CAN:
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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 nonfinancial 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.
95
d
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).
G. 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.
1
1
1e
9- 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
The person is taking proactive steps in promoting his or her own wellness
What recovery does not mean
1. Recovery does not mean a person will no longer experience symptoms
2. Recovery does not mean a person will no longer have struggles
3. Recovery does not mean a person will not use medication
4. Recovery does not mean a person will no longer utilize mental health services
5. Recovery does not necessarily mean a person will be completely independent in meeting
all of his/her needs.
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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)
t POVERTY
(due to inability to work,
poor access to reliable medical
assistance, cost of drugs/treatments)
97
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
enerating 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)
I ORIENTAL ILLNESS
■ (improved through
medical care and
rehabilitation)
MENTAL ILLNESS
(recognized/ stabilized)
POVERTY
(Stabilized)
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Sustainable Livelihoods: A definition
Introduction
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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Meaningful work
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
Natural
Human
Financial
Breakdown
Land
Water
Livestock
Aspirations
Motivations
Interests
Capabilities
Experience
Knowledge
Skills
Networks
Income
Savings
Collateral
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
i 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
100
community that the person is stable and potentially available for employment or other income
generating activities.
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 employmen*
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.
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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
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11
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.
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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 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
ran?
3 0^9 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.
Y ?eCteSSa? t0 Strike 3 balance between the rehabilitation model (considering the
2 d d h8 actlvlties by ltself t0 keep the people with mentally illness occupied) and9 the
adnnHnn thUSineSrm°?! ' Th6r6 haS tO be 3 common consensus in proportionately sharing and
adopting the significant features from both the models.
y
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2.m! rlTh'8 30 Hlready e,X'2tin9 Micro Finance set UP (SHG model) at the grassroots level the
ca^be framedfo^hA5 3 P
.<rarryout 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 aao
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 legates and fc
mnrdinaf18
the leVel °f SUppOrt from the society' A holistic approach through sectoral
coordination addressing mental illness will beyond doubt have a ripple of effect.
9
104
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Society
NGOs & Govt.
Empowerment
Appropriate
Tech.& Training
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 Self- Reliance” is the thrust of our
mission.
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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 self-reliant. 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
106
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
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The choice of the activity in 1) is dependent on the availability of the factors listed in 2) -5).
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
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
108
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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
■ 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
•
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Strengthening existing system of CBO”s/ Secondary partner to monitor and
evaluate income generation activities which in turn feeds into overall Basic
Needs India RMS
■ 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
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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?
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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
Relationship
SI
No.
Age
Occupation
Income
Remarks
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:
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(b) Financial sources:
Individual contribution: Rs.
Loan Rs.
(C) Loan: BankO 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:
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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/Orqanisation
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:
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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)
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.
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.
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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.
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.
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 6:
Human rights and UNCRPD - 60 or 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 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
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L 1
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.
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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 subjects 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
comprehensive set
set or
of inrormation
information on
on aa person cover various aspects
I
u
, FILES: Is a Gurnprenensive
like physical, mental, emotional, psychiatric details. The information collected should qive 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.
K
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
fSnH? S6 miStST °Ut S° u6 ti2ieS in Case files’ The life stories are written “P a more reader
-friendly format .This can then be highlighted in awareness building and advocacy campaigns.
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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
b) Why the efforts put by the family failed
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11
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 communitv
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
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Session 2b
Tracking changes through individual case files - model 1
[MENTAL HEALTH - INITIAL ASSESSMENT FORM)
Date
Cluster Area
Field Staff
Field Coordinator
[INDIVIDUAL DETAILS
Name
Age
Marital status
Client number
Sex
Education
Residential address
Manner of identification/Referral source
Informant(s) during interview
/S 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)
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11
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
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[SOCIAL SITUATIONl
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 DURING 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
[Follow up]
Signature
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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:
iviarital 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
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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______
SI Name
Relationship Age
Edn
Occupation
Remarks
Any disability/mental illness in the family:
Marital Life - duration and relationship
Economic status of the family
Combined family income
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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:
■ 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
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III 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
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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
iatment brought
rorward
New cases referred
for treatment during
the quarter________
[ Total
ii
SMD
CMD
Total
Source of Treatment
i.
Camps
2.
Private practitioners
3.
District hospitals
4.
Local medicine
5.
Any other (Specify)
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Total
SMD
CMD
Female
Male
Female
Male
Female
Male
Side effect
Relapse
Brought forward
During the quarter
Number stabilised
Brought forward
During the quarter
Regularity
1.
Regular with medication
2.
Irregular with medication
3.
death
Drop outs
Brought forward
During the quarter
B. Livelihoods
I.
PWMIs
SMD
Male
Caregivers
Total
CMD
Female
Male
Female
Male
Female
Number actively
in livelihood
(stabilization)
activity as on 1st
quarter_______
New cases
involved during
the quarter
Total
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-if
Source of Support
PWMIs
Caregivers
SMD
Male
Total
CMD
female
Male
Female
Male
Female
Consultations to
discuss livelihood
issues
.1
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.
I
I
I
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
I
1.
2.
i. Number of people with
mental health problems
undergone vocational
training
1.
2.
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11
C. Capacity Building
I.
PWMIs
Major
Male Female
Minor
Male
Female
Number
PWMI
Caregivers
Staff
Others
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
Caregivers
Male
Total
Female
Number actively in
SHG activity as on
1st April 2009
New cases involved
during the quarter
Total
ii
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
5.Outings
Marriage of
people with
mental illness
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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)
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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.
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•
•
•
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
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11
Session 4 a
The persons with disabilities (PWD)
(Equal opportunities, Protection of Rights and Full Participation) ACT, 1995
The purpose of this Act is to fix responsibilities on the Central and State Governments to provide
services, create facilities, make schemes and give support to persons with disabilities for their
development. Further provisions are included in the Act to enable them to have equal
opportunities and to participate as productive and contributing citizens to extent of their abilities.
The Act also fixes responsibilities on the Central and State governments to ensure that
disabilities and the circumstances do not prevent individuals with disability from living a full life
and to make a meaningful contribution, according to his/her ability.
Chapter 1: Preliminary
In Chapter 1, legal definition of the terms used in the Act is given. Disabilities recognized by this
Act are blindness, low vision, leprosy-cured, hearing impairment, locomotor disability, mental
retardation and mental illness.
i.
ii.
iii.
iv.
v.
vi.
Blindness
Low vision
Leprosy-cured Hearing impairment
Locomotor disability
Mental illness
Mental retardation
A persons with disability has to be certified by a medical authority that he/she is suffering from
not less than 40% of disability to benefit from the provisions of this Act.
Chapter 2: The Central Coordination Committee
1. For the purpose of this Act, the Central Government shall constitute a Central
Coordination Committee (CCC), headed by the Minister of Social Welfare (now called
Social Justice & Empowerment).
Some of the Functions of the CCC shall be as following:
a. Review and coordinate the activities of Government, Governmental and NonGovernmental Organizations.
b. Develop a national policy on disability.
c. Advise the Central Government on the formulation of policies, programmes, legislation
and projects.
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Chapter 3: The State Coordination Committee
Identical to the Central Coordination Committee, each State shall appoint a State Coordination
Committee, The terms and conditions governing the State Committee shall be same as those of
the Central Coordination Committee, and the functions and responsibilities shall also be the
same.
Chapter 4: Prevention and early detection of disability
Within the limit of their economic capacity, the appropriate Governments and the local
authorities, with a view to preventing the occurrence of disabilities, .Some of the activities listed
are:
a. Undertake or cause to be undertaken surveys, investigations and research concerning
the cause of occurrence of disabilities.
b. Screen all children at least once a year, for the purpose of identifying at risk cases.
c. Take measures for pre-natal, peri-natal and post-natal care of mother and child.
d. Create awareness amongst the masses through television, radio and other mass media
on the causes of disabilities and the preventive measures to be adopted.
Chapter 5: Education
The Central and State Governments and local authorities shall ensure that every child with
disability has access to free and adequate education till the age of 18, and integrate students
with disability into regular schools. Special schools will be set up in government and private
sectors for those in need of special education, and equip these schools with vocational training
facilities for children (youth) with disabilities.
All Government educational institutions and those receiving aid from the Government shall
reserve not less than 3% seats for persons with disabilities.
Chapter 6: Employment
The Government shall identify posts which can be reserved for persons with disabilities,
ppropriate Government and local authorities shall formulate schemes for ensuring employment
of persons with disability and this shall include training of persons with disabilities.Not less than
3% of all poverty alleviation schemes shall be reserved for persons with disabilities.
Chapter?: Affirmative action
The Government shall provide aids and appliances to persons with disabilities. Land shall be
provided at concessional rate for allotment to persons with disabilities for housing, special
recreation centres, special schools, research centres, and for business and to establish factories
by entrepreneurs with disabilities.
Chapter 8: Non-discrimination
Government transport shall take special measures to adapt their facilities and amenties so that
they permit easy access to persons with disabilities, including for persons in wheelchairs.
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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 forthem. 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.
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.
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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.
ill. 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
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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? 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).
ill. 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.
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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
ooecial groups. Emphasis on outpatient care has been made to safeguard the human of the
entally 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
Provision available for the people with disabilities in southern states
(will be sending it later)
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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
a 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
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•
•
•
•
Right to choose treatments
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)
1. 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
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1/
have to take initiatives to “eliminate barriers that people with disabilities face in
buildings, the outdoors, transport, information, communication and services”.
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
nm . ..1."
Rights
Adjustment to the norm
oni
Exclusion
tinr~.........
Little consultation
.....
Acceptance of differences
Inclusion, participation, citizenship
‘Nothing about us without us’
The CRPD and the Right to Work
Shift in focus
Segregated employment
nnr.......
Petty trading
Open Labour Market
Small enterprises
No legal provisions
nrii \
Coverage by employment laws
Limited choice
0DtZZZZ^>
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.
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
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.
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, whi e
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
s, 152
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i I
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.
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.
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 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.
Session 6
Alliance Building: 30 minutes
1. InradZkpaXipatonPan'S ,0 brainS,Orm °n 'he Vari°US S,ake h°'ders,he commdnit>'
2. Trainer lists down the responses in the black board.
3. mAntZi m °Uld Wrie thS WSb and.put al1 the responses in the web, keeping people with
mental illness in the center and linking all the stakeholders in the web.
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.
y
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.
■
tte taine?
2 Prl"CiP'eS
,he'r "fe that t,K>' ne',er compromise on. starting with
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I i
•
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
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?
155
•
Trainer then talks about privacy and
non-judgmental attitude towards clients and their
own colleagues.
Empathy: (35 min.)
Activity 3:
in
‘
I^XPho“Pan,S ’,heV haVe hOne$,ly ever fe,t
a"°,her
"selves
^XnoTjX™1!tSnPirthy helPS y°U unders,a"d ,he “^dual's feelings and helps
’ Si whfeplaX6 SrtT *e°y Sed M
a"d asks
when they explained that they were abusFna thePr(cthharacter) witho“t judgment
previous exercise. If they say yes ask how? 9
sP°use’ other examples given in the
•
SineJ 'then
We also maintain confidentiality
individual to know thlt the incf^tTin^he"^
that iS disturbin9 for any
want to help them
e'r "fe IS being dlscussed by people who say they
“P *“
'
•
confidence in people, both on
Trainer then Xfor Sions tarSSZte SS.0™"”""19 *he i"neSS
Professional Ethics - A Recap: (15 min)
Trainer asks the participants to list what ethics were not foiiowed in the following story:
5 iong years,
local social worker who was part of an Men £ c°unselmg sessions that were arranged by a
that were given to here He was mSed to'S°^ ?hOt wdanttfo take the bitter medicines
medicines for few days Later family strafAd miJin
eJ..the doctor’ got convinced to take
reduced and got sta^aiisedX'SVXng
eng'agemeTtVh^socS^oX Sed rhefem.^^f
/'"k96 he heard about his
informed him about his weddinq said that
7
f'nd
about the shivanna. Family
medicines in future. SociXX was S not
d°eS not want to take
would come to know about the illness Parente vjpr h
tbtkm after marriage has his wife
the responsibility of caring would be shifted to his wife
S°n WaS getting married’
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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.
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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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
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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:
•
•
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•
•
•
•
•
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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.
>ebriefing: 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 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
jpental 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
jome 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
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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
Importance of documentation
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•
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•
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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
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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
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) JRY
c) PMRY
d) ICDS
e) JANMABHOOMI
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f) ADHARA and ASH RAYA
g) GANGA KALYAN YOJNA
h) SCST 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,
Communication - post office, telephones, computers, email facilities, fax
Water
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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
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 :
•
•
•
•
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 action 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?
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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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•
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•
•
Service users as those people who have mental health issues and are using the services.
Caregivers and field staff
SHG 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
Religious institutions
Donor agencies
Media
Hospitals - private and government practitioners, Psychiatrist, Nurses
Trained Community Counselors
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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
PEOPLE INVOLVED
Community
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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
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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.
1. 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.
TP!
1
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
'he 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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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.
rhe 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.
4.
Two home visits to people with mental illness (one male and one female)
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 menta^
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.
Vbat 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 lite.
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/designmg a caring accommodative
and understanding environment to ensure fair treatment to People with mental illness in
the community.
,
x.
.
.
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 mam
182
activity, how it will be included in their development work, what are the community mental health
and development activities.
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.
183
■Mu-
>
4, Documenting individual files and other programme reports.
5. Bare foot counseling/helping skills.
7 Ki^SS^o c^S^Xen^materials.
I:
^peopte W«h mental lUness based on
«SX~n on trade analysis "““S—"
11 Facilitating discussion with the partner organization on the neeo to.
12.5Mng dLOX9onUPneed 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.
and National Rural Health
15 Orienting field staff on district mental health programme
mission.
.
s 16.Orienting field staff on community monitoring.
17. Dealing with emotions and stress management
t8. Demonstrating relaxations exercise
19 Base line document and need for base line
20 Demonstrating documentation and help field staff in practicing
184
..
■
*
...
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 qo 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!
s
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.
r
time, everyone must have one paper a H
.
the group.
- '
ending with 7, they shr0““*„Pa^e Trained also would participate in the game
thPir will be one winner of the game.
- 6 Thr^o in Common Game
1~\hey (as a group) mustteit the restotthe groups
3
/ things they have in common.
/
1. Crete of Friends Game
S This is a great greeting and departure for a large 9™^^ Jnb,he room is almost impossible
than one day together and the chance sid9e by sjde), one inside the other and h
- A Form two large circles (or simply form two lines s de y
AsR the circles t0 take one step in
Ag==aifexwstt-®
|the^lves.
Marooned Game
can use a
A—
solving styles and promotes teamwor .
I I
li. Decision making
WI
"X.
1«'
.
speu^you^ave XTpXgem iilre 17 year oid
186
r
disabled boy, 30 year old pregnant lady, 65 year old man and his wife 60 year bld woman, 20
yfe.ar 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 throve
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 tol
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, I
removing the buttons of the shirt, changing the hair style, changing the place of pen etc). ThcfV
observer group is called, they would stand in the line facing their partner, they are asked to tej^
the changes in their partners.
13. Group untangle
I
The whole group of teens will assemble in a circle with each person claspipcjjaJaand of someone
different. (In other words, they will be holding one person’s. ha“fifd^vith their" left hand and
someone e/se’s with their right hand) IMPORTANTTI; cannot be the person next to therrf
Now that they are in aj^omplete jumble, blow t’ie whistle and give them one minute to,g$t
untangled wittiouMbfting go of each other’s hands.
7
,
1
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