About KHPT
III. Case studies on Counselling and Reformation
An estimated 150 million Indians need active mental health care intervention according to the National Mental Health Survey (NMHS) 2015-2016. Common mental health disorders (CMDs), including depression, anxiety and substance abuse affect a significant section of our society. In low resource countries like India, some of the important factors contributing to the causation and recovery of mental health disorders are social in nature. There is a long-established relationship between mental health and social variables like employment, education, living standards, environment, access, equity, and others. A bidirectional relationship exists between social adversity and mental health disorders; individuals from socially and economically vulnerable groups are at a significantly higher risk of suffering from mental health disorders which in turn contributes to impoverishment. These factors also cause considerable obstacles in accessing and utilisation of mental health services. Mental health care interventions for these groups are particularly challenging.
Providing mental health care to socially marginalised communities has also largely been neglected by the National Mental Health Program (NMHP) in India. The focus of NMHP has been mostly on providing basic mental health services to individuals with severe mental health disorders. The District Mental Health Program (DMHP) in India was rolled out 25 years ago with the aim to provide community mental health services at a primary mental health level is currently operational in only 27% of districts and has a shortfall of required mental health professionals. In India, where there are hardly 0.3 psychiatrists, 0.07 psychologists and 0.07 social workers per 100,000 people, individual mental health care interventions are resource intensive. There is a large ‘treatment gap’ all over the country, but especially so in rural areas, northern states and amongst the socially disadvantaged.
The sheer magnitude of the problem combined with stigma and discrimination and the existing treatment gap provide some compelling reasons to move towards a public health approach to mental health as advocated by the World Health Organisation. The public health approach
shifts the focus from the traditional individual-focused deficit driven model of mental health to a whole-population, strength-based approach. The framework promotes the adoption of a multi-tiered approach which not only targets the population suffering from severe mental health issues but also proactively addresses the mental health needs of all individuals within a community. The public health approach provides a direction towards reducing the burden of mental disorders by thinking of ways to increase universal access to appropriate and cost-effective services, including mental health promotion and prevention services addressing the needs of at-risk population.
When it comes to addressing the needs of at-risk population, decentralisation and the role of social sector organisations become extremely crucial in a low resource country like India. These organisations play a critical role in health promotion and facilitation of educational activities. Increasing involvement of social sector organisations in providing mental health care interventions can not only help reduce the treatment gap but also help in reaching out to vulnerable communities at risk.
Against this backdrop, the three case studies by ‘Seva Kendra’, ‘Project Second Chance’ and ‘Ishwar Sankalpa’, highlight the need for various stakeholders to work together in providing mental health care to at-risk populations like truck drivers, jail inmates and the homeless. They highlight the need for active involvement of social sector organisations in need assessment and providing mental health support to vulnerable communities.
The first case study by ‘Seva Kendra’ depicts the challenges faced by long distance Multi-Axel container/ truck drivers and the difficult and exploitative work conditions under which they must operate in an unorganised sector.
They work for long hours, face multiple health related issues, engage in unhealthy lifestyle practices which impacts their life expectancy. The SAMBANDH program by Seva Kendra was an attempt to improve the quality of life of these workers and provide them with much needed psychological, social, and physical support.
The interventions were carried out in five districts in West Bengal and the project was funded by the MAERSK Group, under their CSR (Corporate Social Responsibility) program. The SAMBHANDH program reached out to almost 10,000 truck drivers. Their primary area of intervention was to restore
their self-esteem and provide them ways to change their unhealthy lifestyle practices through systematic psychological and behavioural activities and make them more visible in public domains to help advocate for their rights along with others in the unorganised sector.
The program utilised various innovative ways like street plays, playing cards and performing magic shows along with regular health check-ups, group, and individual counselling to spread awareness and educate. The program also helped the primary beneficiaries to access schemes, social security, and insurance by helping them with the documents and took a softer advocacy and awareness approach.
The outcomes of the program have been quite encouraging, SAMBANDH was able to reach out to many primary beneficiaries; spread awareness about road safety, safe sex, personal hygiene, insurance, and government scheme.
They could also convince some of them to reduce their substance use intake, provide health check-ups, HIV testing and teach them yoga and exercises. The secondary beneficiaries like the wives and children also received training in reproductive and child health related issues. This case study offers interesting insights into the challenges of implementing a program like this and important observations in furthering the rights of truck drivers in the unorganised sector.
The second case study ‘Project Unlearn’ focuses on the reformation of prisoners through context-based educational intervention. The goal of the program was to reduce the rate of recidivism, improve functional literacy, create learning spaces to discuss about relevant issues like gender-based violence, life skills and train internal service providers to support the inmates.
They have designed and developed an educational kit called ‘Pahal’ covering a 90-day curriculum to initiate dialogues around relevant issues along with the regular curriculum and create a layer of peer educators who could help initiate change by implementing the kit and offering cognitive and socio emotional education to the inmates. The language and design of the kit is informed by the observations made inside the prison and inputs from different stakeholders.
The case study takes us through a fascinating narration of the experience of designing and implementing the educational kit, the various challenges encountered in engaging the inmates, making the kit interesting, relevant and age appropriate. The study also shares the experience of training five
volunteers as peer leaders to act as agents of change within the prison system and provide important inputs to contextualise the kit. These peer leaders in their own unique ways were successful in making other inmates attracted towards the educational initiative. The collaboration with the peer leaders also helped the team in creating a set of comic books around issues like gender violence, rape and POCSO to sensitize the inmates. The kit is basically intended to provide other organisations with a teaching aid to target at-risk youth.
The third case study documents the experience of Ishwar Sankalpa, an NGO based in Kolkata, addressing the psychosocial needs of the homeless.
Homelessness has been growing alarmingly over the years, growing by almost 40% between 2001 and 2011 at the national level and by almost 50%
in West Bengal during the same period. Evidence shows that the homeless face multiple problems – a lack of amenities such as water and sanitation, protection from inclement weather, and harassment from police and other authorities who frequently evict them and keep them on the run. Perhaps as a result, homelessness is often associated with mental illness. Studies have shown high incidence of psychotic disorders, substance abuse and bipolar mania among the homeless; and lack of access to proper medical treatment was one of the causes for them to become homeless in the first place. It is estimated that there are an estimated 400,000 wandering mentally ill people in India, an indication of the staggering proportions of this problem.
Ishwar Sankalpa’s program – Naya Daur – takes a unique multi-pronged approach to reaching out to this highly vulnerable population: urban homeless, who are also suffering from psychosocial disability. Starting with the belief that there is an inherent capacity for care and compassion within each community, the program seeks to leverage local support for the homeless in their dwelling site, rather than resorting to relocating them to an unfamiliar location. This low cost model brings together community resources that are commonly available everywhere – the local teashop owner, shopkeepers, and so on – to provide food, medicines and other necessities for individuals in their area who are both homeless and incapable of caring for themselves due to debilitating mental illness. This serves many objectives: it builds a sense of community, where people build a joint responsibility for caring for those most in need; it shares the burden, both financial and emotional, of providing
sustained care and support; and, most importantly, it confronts the stigma associated with homelessness and mental illness directly, showing that it can be treated and managed through sensitivity and compassion.
Following a systematic approach, Naya Daur has created a replicable model for addressing this issue. Their own intervention has touched 1,200 lives in 40 wards of Kolakata, providing them with basics such as food, clothing, healthcare and the human touch. They have enrolled over 200 voluntary care givers in these communities, besides rehabilitating several homeless back into the workforce as well reuniting many with their families. Importantly, they have secured entitlements in the form of Aadhaar cards, Disability cards, bank accounts, PAN cards and gratuity schemes for many of the homeless.
These case studies provide valuable insights into the experience and challenges of designing and delivering mental health care to vulnerable communities and help them lead productive lives. The key takeaway from these case studies is the need to contextualise the interventions and incorporate the experience and knowledge of the primary stakeholders while planning and implementing these interventions.