Community Psychiatry – Transcontinental Lessons of the Last Quarter Century - T. Manoj Kumar Clinical Director, Mental Health Action Trust, Kozhikode, Kerala, India
Abstract
Fueled by the discovery of effective medications and the debilitative effects of psychiatric institutionalization and driven by the social winds of change, community psychiatry took shape all over the world. The gradual closure of asylums and the move to community signified not only a geographical shift, but also led to the development of a whole new raft of practices in delivering services in the community. Many of these have become mainstream practices elsewhere. After a promising start, initiatives in community psychiatry have stalled in India, with the lack of resources being the most obvious cause. For various reasons, the field of social psychiatry has also not been in the limelight as psychiatry shifted its focus to the possibilities held out by biological psychiatry.
This is unfortunate because the need for broader models is never more relevant than now, as social inequities continue to grow. Therefore, the time is ripe to look back over the developments in community psychiatry of the last quarter-century and search for relevance in the light of our current realities. What are the main developments and more importantly, can these be implemented in a cost effective manner in India? This article is a reflective attempt to argue for the feasibility of models using those principles but adapted for our social and economic realities.
MHAT - The evolution of a community mental health service - T. Manoj Kumar Clinical Director, Mental Health Action Trust, Kozhikode, Kerala, India
Abstract
More than 10 years ago, I left my job in the NHS and life in the UK and along with friends, embarked on an adventure in community psychiatry which has evolved into a distinctive model of mental health care delivery for the underprivileged. The reach of our work has grown beyond our wildest imagination, reaching out to more than 4000 people with severe mental illnesses, all of whom are from the economically poorest sections of the society. We now have a presence in 8 districts of the Southern state of Kerala, India
through a network of 54 community partners, all of whom work with us in providing community mental health care. We started out with a simple question – is it possible to provide good quality, comprehensive, free mental health care to the poorest people with severe mental illnesses? The shortcomings of the existing services were clear – an underfunded and inadequate public psychiatric service and unaffordable private sector services. In both systems, the numbers of trained professionals were low and the treatment consisted mostly of medications alone. Provisions for psychosocial interventions and rehabilitation were lacking. To read the entire work
Community mental health services in India: The pandemic and beyond - T Manoj Kumar, Clinical Director, Mental Health Action Trust, Kozhikode, Kerala, India
Abstract
Both popular and professional narratives during the COVID pandemic have focused on the perceived mental health needs of the population. Anxiety and distress have figured high in the list of mental health problems anticipated either during the crisis or in the aftermath. Some of this has been based on previous experience of disasters, but the current pandemic is unique in that there are no modern-day comparable equivalents. A number of cross sectional studies, many from China, have reported high levels of symptoms, particularly anxiety. However, the interpretation of these is difficult as it is not clear if the reported high scores on questionnaires translate into the presence of diagnosable mental disorders. By focusing on the population effects of the pandemic, we are in danger of neglecting the needs of the existing severely mentally ill. It is also becoming increasingly clear that the pandemic could continue for months or years. Existing mental health services have been badly affected by the ongoing lockdown. Considering that the treatment gap is already wide in India and resources stretched in meeting the existing needs, we cannot afford to lose the gains we have made in meeting the needs of people with severe mental disorders. This paper describes, in the light of an example from Kerala, how we can adapt to the changed circumstances without care being significantly compromised. It could also be that these changes forced on us now, could actually make the delivery of mental healthcare even better in future. The COVID challenge also provides opportunities for reform.
Evaluation of Community Mental Health Intervention - MHAT, Calicut, India - Sonja Brouwers, University of Amsterdam, Management, Policy Analysis and Entrepreneurship in Health and Life Sciences
Abstract
The inadequacy of hospitalized mental health care in low and middle-income countries (LMICs) has led to the emergence of community mental health initiatives who aim to fill the treatment gap affecting mostly rural areas. In India, community-based mental health care has played a big role in providing basic mental health care to those most in need and relieving the burden on families as informal caregivers. One of these initiatives is Mental Health Action Trust (MHAT), who has been providing mental health care and rehabilitative services to the economically backward in several districts in northern Kerala.
The lack of reportage on mental health in LMICs calls for an evaluation of mental health models, as to contribute to knowledge on community based mental health care. The MHAT model was evaluated according to a new movement that has emerged from the West, focusing on the holistic recovery of mental health patients beyond symptom remission. This approach aims for mental health programs to incorporate norms, values and services that will facilitate the individual recovery process of the patient. While the principles of the approach are based on Western
studies, they show correspondence with the aim of multiple community-based care services focusing on rehabilitation of people with mental health problems in LMICs. Current research into the recovery-oriented approach in LMICs is limited, sparking interest into the applicability of this approach in low socio-economic community-based settings, specifically rural India.
Exploring family resilience in a community mental health setup in South India - Hena Faqurudheen, Sini Mathew, T. Manoj Kumar
Abstract
The purpose of the study is to identify the socio-demographic characteristics and understand the level of family resilience of clients and their caregivers seeking treatment for mental illness within a community mental healthcare set-up. The sample consists of 60 respondents from impoverished urban and semi-urban families whose family members are currently undergoing treatment at the community mental health clinic run the Mental Health Action Trust (MHAT), a local NGO based in the northern
region of Kerala in South India. The methodology requires the participants to report the current symptom severity for their family members suffering from chronic mental illness, using the 18-item Brief Psychiatric Scale. They were then interviewed about how different aspects of family resilience applied to their own lived experiences as primary caregivers using Sixeby’s Family Resilience Scale based on Walsh’s conceptual framework of family resilience. The study is expected to contribute to understanding how families might be nurtured and strengthened using Walsh’s family resilience approach in an Indian cultural context.
"Indian Journal of Social Psychiatry" Community Mental Health: lessons from India - Mental Health Foundation podcast
Abstract
Dr Manoj Kumar, talks about his work in providing community mental health care for the poor people in the Indian state of Kerala. He talks about the success of his project and the importance of community buy-in, also offering lessons that the UK could take from the system.
Design and Evaluation of Peer Supervision for Community Mental Health Workers: A Task‑Shifting Strategy in Low‑Resource Settings
Abstract
The use of Lay Mental Health Workers (LMHWs) to tackle the treatment gap in low-resource settings is well established,
and although they often receive training, the potential of proper supervision to improve outcomes remains untapped. Indeed,
given the strain on expert resources, peer-supervision models based on supervisors’ seniority of work experience have sig-
nificant potential especially in relation to community knowledge and embedding of LMHWs. This study summarizes the
evaluation of a pilot program for peer supervision on the basis of Social Cognitive Theories of Self-Efficacy for LMHWs in
Kerala, India. Two experienced LMHWs worked as supervisors for a total of 12 LMHWs over the course of a year. These
participants were subsequently interviewed to analyze their experiences in order to evaluate the potential of peer supervi-
sion and distil relevant information to improve future training of LMHWs. The findings include improved performance and
emotional support for the participants.
Challenges and sustainability of Indian mental health: evaluating volunteer-based community mental health clinics with a complex adaptive system framework
Abstract
This study aims to evaluate how a community psychiatry model, referred to as the Mental Health Action Trust (MHAT) in India, provides decentralized care and comprehensive services to people with severe mental illness living in poverty. Using the complex adaptive system (CAS) framework, the authors aim to understand the factors that contribute to the diverse outcomes of the MHAT community mental health programme as observed in four different locations.
Community‑based Psychosocial Intervention for Persons with Severe Mental Illness in Rural Kerala: Evaluation of Training of Lay Mental Health Workers
Abstract
Background: High‑quality mental health care is scarce in rural India. The Mental Health Action
Trust a Nongovernmental Organization based in Kozhikode, South India, has been providing free
mental health services to the economically disadvantaged people in the surrounding districts.
Comprehensive multidisciplinary care is provided through existing health‑care clinics through
training of lay mental health workers (LMHW). The current paper evaluates the classroom training
methods employed to educate the LMHW. Materials and Methods: The training module designed
after coordination and need assessment was delivered through classroom training sessions by trained
trainers over 2 months weekly 6 h and completed by 13 volunteer LMHW (5 males and 8 females
and who were in the age range of 22–56 years) could complete all the modules of training. The
evaluation of training was done quantitatively and qualitatively. Results: The LMHW’s knowledge,
attitudes, perceived interpersonal skills, and confidence levels demonstrated a noticeable change
following the classroom training program. Conclusion: It is feasible to train LMHWs to deliver
psychosocial interventions for people with severe mental disorders and their families in rural India.
In addition to classroom training, case‑based training and proper ongoing supervision are required to
improve their skills, attitudes, and knowledge
Coping with complexity in a wellbeing oriented, task-shared, community mental health setting, Kerala, India | Rekha Pallikkuth
Abstract
The Complex Adaptive System (CAS) model was employed to evaluate and explore the reality around Mental Health Action Trust(MHAT) community clinics in Kerala, which offer a rich empirical and experimental pool of data collection, exactly because it aims to serve the communities in a most efficient and effective manner. The research was set up as to offer solutions to persistent problems in Community mental health, such as e.g. issues of collaboration and communication within a system of partners, the knowledge, skills and confidence of Lay Mental Health Workers (LMHWs) and how to train or supervise them, as well as the question of incorporate technology. The totality of this thesis pertained to the importance of complexity experienced by LMHWs conducting wellbeing-oriented community mental health interventions in low resource settings in India. In addressing this topic, it covers both practical questions of types of complexity particular to the Indian context, and the more theoretical questions of applying complex systems analysis and integrating social development in mental health care. This thesis points to the need that in order to meet the practical needs arising from communities and the LMHWs that serve them, approaches need to be reconfigured to accommodate not only the full scope of the pursuit of wellbeing, but how that pursuit must include a dialogue between more prescriptive structuring and attention to the constantly evolving realities emerging from within health organizations. Where more holistic approaches to mental wellbeing are essential to tackle emerging problems in global mental health, they also create unique challenges for LMHWs relating to their shifting roles, such that they must be empowered through training and supervision to become complexity leaders, capable of making context-responsive, independent decisions. Operationalizing this process through use of theoretical models related to empowerment and self-efficacy proved effective. Tensions and conflict arising within the process from the way these external and internal stimuli affect the system appear to be mitigated by a deepening of interconnection through for instance the experience sharing that is facilitated by peer support. The research on which this thesis is based shows that many of the challenges within the organization can be attributed to the ways in which different agents in the system are responding to transitions with insecurity such that emergent behavior is negative. Yet, those challenges also indicate the directions for growth as targeted and dynamic input can shift the self-organization of the organization into new directions. Finally, this research demonstrates that LMHWs can be empowered to productively self-organize and interact with other actors in the complex adaptive system of mental health in mutually beneficial ways. This was accomplished through visible changes in knowledge, attitude and practices in training as well as increasing self-efficacy through peer supervision and online supervision that enabled self-determination through flexible, strength-based supervision. Technology proved an effective way to extend limited human resources. Working with complex systems requires case-by-case flexibility and constant adaptation not just for mental health interventions but also for supervision. Support of LMHWs must be iterative in nature and leverage the potential of technology to extend limited resources.
A review of theatre interventions and mental health: inspiration, elicitation and dissemination
Abstract
Background: There is limited knowledge of how theatre interven-
tions have been deployed to address mental health issues in low
and middle income countries (LMICs). Our aim was to examine the
role of theatre as a research activity and explore the ways in which
its research potential had been actualised in the literature, and
examine the extent to which authors have addressed LMICs.
Methods: We undertook a scoping review informed by PRISMA
guidelines, which yielded an initial capture of 1200 items, which
was narrowed down to 21 papers, including some relevant inter-
ventions from Canada and the UK too.
Results: The literature demonstrates extensive experience of using
theatre interventions, which used a variety of performance modal-
ities. Theatre is used as a way of inspiring change, eliciting data
from audience members and participants and as a way of dissemi-
nating public health messages or research findings.
Conclusions: We conclude with observations about areas which
deserve further attention, such as critical deconstruction of expert-
approved health messages, or the potential of the originating
radical theatrical traditions to question patterns of power and
legitimacy