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Submitted by PatientsEngage on 9 October 2016

Moyna Sen writes on the National Conclave for Community Mental Health held in July organised by Anjali that touched myriad issues.

A simple definition of Mental Health goes this way: ‘Mental health includes our emotional, psychological and social well-being. It affects how we think, feel and act. It also helps determine how we handle stress, relate to others, and make choices. Mental health is important at every stage of life, from childhood and adolescence through adulthood.’

The National Conclave for Community Mental Health, put together deftly and thoughtfully by Anjali, worked towards addressing Mental Health in the wider gamut of how it operates in a Community. They got together an extraordinary panel of practitioners and activists from across the country, 

What the Conclave decided to tackle in a comprehensive way is if a mentally ill person can benefit from proper medication, as he certainly will, he will gain equally from living in and being helped out by a supportive community.

As it was expressedly mentioned by the organisers of the Conclave - in the battle to gain supremacy, it is puerile to undermine the importance of medicines in some respects and extremely ignorant to dismiss it completely as every person in need of medication rightfully should reap the benefits of modern medicines. The conflicting paths to reach a solution should hence be complementary to each other, and not act as a deterrent to ring in a happy note for those affected.

The Conclave set out to be a learning experience for all those present, with discussions ranging from the history of Community Psychiatry, which is not very old, hailing back a mere 30 years or so, the importance of choice that an individual should be able to exert in any given space, sexuality, desire, issues related to women in general and the very dynamics that an inter-disciplinary approach always promises to throw up in an ensuing dialogue.

The thing which set the Conference apart, besides the diversity of speakers and topics, was the clarity and articulateness of the speakers. They spoke honestly, from the heart and with reason.

History of Community Mental Health

Thirty years old is all that the history of Community Mental Health can be traced back to , rued Sanjeev Jain, a professor of Psychiatry at NIMHANS, Bangalore. And this part of the world does not even have a history of mental asylums, the first of which were found in the south of Europe.

Vaishnavi Jayakumar, an activist and a co-founder of The Banyan, laid bare the horrors of the Erwadi tragedy in 2001, where 28 inmates who were chained to posts, perished in a fire, and even though it should have been a turning point for mental health treatment in the country, it merely ended up being a “string of PILs”.

Bhargavi Davar, the founder of Bapu Trust, also felt there was a dismal lack of recorded history of Community Mental Health and that one also needed a fresh approach towards a Mental Health law, free from the shackles of a colonial clout.

Diagnosis and Treatment Gap

Dr Pratima Murthy, also a professor from NIMHANS, started by saying, “ I am proud to be a psychiatrist and conscious of my role about taking care of the mentally ill in the country”. Talking about diagnosis and ‘Treatment Gap’, she said mental illness does not necessarily entail “pill for every ill”. It requires understanding because every psychological problem does not lend itself to diagnosis. According to her, Community Mental Health means different things to different people and the Conclave needed to be clear about that, as it was more important to find common grounds on which to develop rather than just talk about polarised views.

Ratnaboli Ray, a trained psychologist, activist and the founder-director of Anjali raised rather incisive questions about the teaching and practice of Psychiatry and whether one can possibly arrive at a formulation amidst so many difficulties that one encounters, specially in field work, like Anjali does in their Janamanas campaign, which is actually a door to door campaign and quite singular in its reach and potential. In fact, the Conclave also doubled up as an occasion for the launch of the Janamanas Replication Manual Janmanas is a successful door-to-door mental health project run by Anjali, at Rajarhat, Kolkata, and at Cooch Behar, north Bengal.

Ratnaboli Ray raised the claim of safe care in diagnosis, and actually how ‘safe’ is that. Community living throws up issues like poverty, alcoholism, domestic issues and looking at all this, can one actually come up with a standard formula? Perhaps treatment gaps also point towards the need to reconstruct communities with their inherent vagaries.

Abhijit Nadkarni, an Addiction Psychiatrist from Goa, felt that diagnosis may be an over rated thing and is often imposed on a person, and in doing so, we certainly minimise the importance of the person. Mani Kalliath, a community health activist who has been associated with the resource group Basic Needs India (BNI) and has managed to touch the lives of about 25,000 people across some 8 states in India, said that the initial approach to community mental health was a bottoms up approach where all the strands like the caregivers, local supporters, ngos, pitched in. Out of this came the set of needs which, eventually, provided the directions as to how to proceed.

Women in Community Health programme

Kolkata-based activist Shampa Sengupta, however, seemed to feel that the breakdown of communities and the isolation which is integral to today’s living is the crux of mental health problem today. Anuradha Kapoor of Swayam reiterated this by the claim that violence and mental health are closely linked. It is not just isolation, but insecurity and a lack of trust which have paved for mental illness, as her years of experience with the survivors of abuse have revealed. She is all in support of community support as one to one counselling doesn’t work always . But then, communities also have to be prepared to deal with mental health.

Sexuality and Community Mental Health

A rather honest and engaging chapter was the discussion on Sexuality and Community Mental Health Programme, mainly because of the speakers who were forthright and disarming in their candidness. Pramada Menon, co-founder of CREA, touched upon how important it is to be aware of one’s own body and its needs; Anindya Hazra, working on transgender rights, talked about how it is a double stigma when one is a queer and also suffering from mental illness and whether the community is again ready to handle it; Dr Jairanjan Ram, a Kolkata-based Psychiatrist, talked about how often he has come upon flummoxed parents trying to grapple with their child’s ‘queer’ sexuality and hoping the doctor will help regain ‘normalcy’, and again an issue when parents find their disabled child have sexual needs.

Choice and Voluntarity in Mental Health treatment.

The next segment was probably a key segment of the Conclave, as it dealt with the all important question of Choice and Voluntarity in Mental Health treatment. Anirudh Kala, a Punjab-based Psychiatrist, felt Choice was intertwined with Consent and when we do talk of ‘Consent' (to being treated) in Mental Illness, it is a miniscule percentage of 5 to 10 per cent of mental health patients. But Debashish Chatterjee, a Consultant Psychiatrist by profession, opined that a person is at a better position today to make the choices and implement them as well. Abir Mukherjee, a Psychiatrist from Kolkata cited Article 12 of UNCRPD which upheld the dictum of Capacity vs Consent and felt that there should be a separate legislation for capacity assessments and the resultant treatment. In other words, the whole chapter of decision making in Mental Health treatment required special looking into. Shals Mahajan, a queer feminist activist and writer, said that when trans gender people are brought to psychiatrists, the latter tend to loom large as authority figures. How much of choice is actually divested in the patients in this case since they do not conform to the norms of the society and hence termed misfits?

Nature of scaling and evaluation

Dr Vikram Gupta, a public health professional from Bhopal, speaking on ‘Nature of Scaling and Evaluation’ made a whole lot of sense when he began by saying that to him scaling means a scaling of opportunities. Much experienced in the scale of grassroot work, for Dr Gupta a mental hospital is always a community hospital, and never a standalone institution. ‘There are so many Indias within India’, is how he explained the vast gap in mental health treatment in rural and urban India, and the test is how even the sophisticated scales hold good in the rustic heartlands. 

Scaling for Sarbani Das Roy, co-founder and director of Ishwar Sankalpa, means output, more efficiency, more utilisation and also a scaling up of impact. According to her, there are 4 constraints in the Scaling up operation: lack of money, political will, capacities & accountabilities, and haziness about how small pilot projects can actually be scaled up.

The overall feeling was that there probably are no perfect models to aspire for a scale up. As Dr Gupta emphasised, that statistics show that there are more cases of mental illness in our country than that of diabetes and yet the government reserves more funding for diabetes. This would call for a scale up. 

Karen Mathias of Emmanuel Hospital Association was of the firm view that Community Mental Health essentially means working with communities, not outside them. Which is why she feels art, dancing and music are all important for mental health to flourish. 

Dr Alok Sarin, a Consultant Psychiatrist from Delhi, summed up the learnings at the Conclave succinctly. Praising Anjali for their remarkable and sustained efforts at rehabilitating mental health patients with the Chaighar and the recently launched Dhobighar projects, Dr Sarin said Community Mental Health deserved to be thought of differently. The answer to the stumbling issues are not how many ways and models are there, but how well the communication is between the different approaches and to fully appreciate that any Community Mental Health project is essentially rooted in the community. The road map can, of course, be defined by the already successful existing programmes. And to sum it all up, he said, if the Conclave can be a catalyst for future endeavours, it will be very useful.

What, however, one did miss at the Conclave was the patient’s or the caregiver’s view point, as a Community discussion without either does not have a sense of completion. A discussion on Choice and Consent with Mental Health patients as participants would have definitely attained new heights. We can certainly look forward to it.