Reinventing India's Mental Health Care - UCL


UCL Cultural Consultation Service & International links Reinventing India’s Mental Health Care The problem

“There is an urgent need to reinvent a new discipline: a locally valid mental health theory and practice for the vast rural Indian majority; to appreciate how our own cultural identities and institutions have shaped our theories, teaching practices and priorities; and to rethink how this might impact on our patients in the clinic” Dr. Sushrut Jadhav, UCL

There is only one psychiatrist for every 400,000 people in India – one of the lowest ratios anywhere in the world. But even if there were more, marginalised people in India may remain more likely to turn to temples and faith healers than mental health professionals. Mental disorders remain shrouded in social suffering, discrimination and humiliation. Women are often abandoned to institutions with no prospect of returning home. This is both a public health and cultural issue. The reasons for these attitudes are complex and varied, and are deeply embedded within local cultures. Yet there is not a single text book of psychiatry in India that is based upon local problems including ethnic conflicts, poverty, dowry deaths, farmer suicides, corruption, etc. Clearly, pills alone are not the main solution. Mental health theory and practice in India remains a watered down version of Western psychiatry that promotes global solutions, and edits out local forms of suffering. Consequently, such vital matters are neither heard nor documented by mental health professionals in India. What we need to do We need to encourage and enable a dialogue between health and social sciences in India; we need to reduce the stigma and discrimination associated with mental illness; we need to provide support and dignity for carers and families; and we need to reintegrate patients back into the workplace and society. But before we can develop new interventions for mental disorders, we need to recognise that the experience of illness, the ways it is understood and treated, differ widely between different

cultural groups. We need to understand local attitudes to mental health; we need to educate families and community care groups on their terms, not ours; we need to train a new generation of health and community workers, who appreciate the importance of local cultural identities and how they affect local responses to mental health. Ultimately, we need to ensure that those who need help can get it, without stigma, discrimination or exclusion. We urgently need indigenous text books for training and not rely upon the continuing colonial import of western psychiatric models. Rethinking the role of culture in mental health UCL researchers are playing a leading role in understanding how mental disorders are shaped by cultural identities. Dr Sushrut Jadhav (UCL Senior Lecturer in Cross-Cultural Psychiatry) is piloting with colleagues in Chennai, Pune, Assam, Delhi, Uttar Pradesh, Gujarat, & Andhra Pradesh to understand how local factors shape mental health and the suffering of marginalised groups – from the development of mental disorders, to the way communities react, to the ways in which people do or do not seek and receive help. From this pilot understanding, we aim to develop culturally-sensitive theory and interventions for the benefit of marginal Indian communities, and also for other low income nations. Examples form current pilot projects in India I. Caste, Stigma & Well-being Jadhav, Davar, & Jain. What is the stigma of Dalit Caste? How does it differ from stigma of mental illness? How does it change after conversion? Budddhist Temple (Vihara) at field site in Pune depicting conversion of Dalits to Buddhism & establishment of newer caste lineages. Study funded by the British Academy, 2011-12

II. Suicide epidemic amongst cotton farmers in India: a clinical ethnographic study Kannuri & Jadhav A staggering 2,56,913 Indian farmers have committed suicide over past 20 years How can agricultural and mental health services develop culturally sensitive interventions? .

Phd project funded by the

III. Exclusion and self-exclusion from Supplementary Nutrition Programme

Lapsi, a sweet from wheat flour usually greasy; is dry, partially cooked and much wasted at an Anganwadi Centre (AWC) in Gujarat. Gujarat is a State with high economic growth and high per capita income; yet child nutrition status is poor and has remained stagnant over a period of 13 years. Evidence to date suggests that the ICDS is grossly underutilized in Gujarat despite strong legislative and fiscal support.

Nakkeeran, Bhattarcharya, & Jadhav, 2011-

Wellcome Trust Capacity Strengthening Strategic Award to the Public Health Foundation of India IV. Human-Elephant conflict in Assam, India Human elephant conflict is mediated through alcohol. Families of human fatality lead to severe mental health morbidity mainly to widows and children

What are the hidden dimensions of Human-Elephant conflict in Assam? How does alcohol mediate this conflict? How can wildlife conservation and community mental health services co-ordinate? How can the clinic be more responsive to local culture?

The Elephant Vanishes: Impact of humanelephant conflict on people's wellbeing. Health & Place, Jadhav & Barua (2012): UCL & Banyan Academic for Leadership in Mental Health cience/article/pii/S1353829212001268


Interdisciplinary research project on stigma of homeless women with mental illness in South India Introduction Homeless, mentally ill women in India face stigmatisation from society and their families. Many are unable to return home and face unemployment, violence and discrimination. Accessing treatment is difficult for most, but the Banyan, a mental health NGO based in Chennai work to address this by providing long term support and treatment in a holistic community environment. Aims & Objectives • Analyse the impact of stigma on homeless mentally ill women in India • Test the hypothesis that industrialisation leads to worsening of stigma • Contribute to policy change in public mental health in India. • Develop a research collaboration between partners at UCL and the Banyan-BALM, an NGO in Chennai, India. • Support local researchers in developing new skills in qualitative methods, including ethnographic fieldwork. Activities • Phase I: Conduct a brief clinical ethnography, including in depth interviews, with homeless women living in a ‘Protected Community’ setting at the Banyan, Chennai, South India. June 2011-December 2011. • Phase II: Interview stratified randomised sample of a matched rural and urban population in Tamil Nadu, South India, using newly developed 24 item Stigma Questionnaire (n=245) to test the industrailisation hypothesis. Analysis and results expected to be completed by October 2012.

QuickTime™ and a decompressor are needed to see this picture.

Chennai, Study site

Protected community, Banyan, Chennai

Outputs & Impacts •Ethnographic paper submitted to ‘Teaching Anthropology’, a peer reviewed journal, Royal Anthropological Institute, UK. Quantitative findings to be submitted for publication by December 2012. • Results from the on going study have enhanced teaching content of the UCL/BALM short courses in social science and cultural psychiatry, with a planned course on Stigma in Nov. 2013

•Poster & Talk at CALT symposium, UCL, 2011, on teaching & research collaboration •Further successful research-teaching grant applications to develop a joint international teaching/research programme with UCL-TISS (Tata Institute of Social Sciences)-BALM partners. Conclusions • The language of stigma becomes transformed from local idioms into a psychologized or ‘medicalised’ terminology, & to a human rights/advocacy discourse learnt at the Banyan. • Priorities for these homeless women are located in security, support, access to families, if not full return • Self-esteem and confidence came through useful employment - paid or voluntary, and opportunities for developing and integrating within new communities. •The ethnographic study generates important questions to further examine the stigma of homelessness as conceptually distinct yet overlapping with stigma of mental illness.

Jane Derges1, Sushrut Jadhav1, Lalit Narayan 2, Vandana Gopikumar 2 & Roland Littlewood3 1Unit

of Mental Health Sciences, University College London, UK Chennai, India. 3Dept. Of Anthropology, UCL 2BALM,

Culture and Mental Health: an ethnographic study of what shapes an Indian Psychiatrist. 2013Clement Bayetti (MPhil)

Primary Supervisor: Dr Sushrut Jadhav

Secondary Supervisor: Dr Jose Calabrese

Clinical and symbolic realities constructed by Indian trainee psychiatrists during their training often result in concluding ‘Western’ constructs of mental illnesses are deemed “real”. Psychosocial and local cultural aspects are thus considered marginal. Psychiatric illnesses are thus viewed as a variation of Western prototypes, rather than conditions in their own right, shaped and interpreted by local Indian context and understanding. Consequently, the cultural & professional identities of Indian psychiatry trainees are shaped by ‘Western’ cannons, resulting in incongruences between psychiatrists’ professional identities and cultural realities of local communities who place their trust in the State’s biomedical care and services. Aim and objectives 1. Understand how Indian psychiatrists learn & are taught during their post-graduate training. 2. Understand processes through which training a) constructs their professional identity, b) shape their clinical activities, and c) leads to challenges in addressing community concerns. 3. Generate an anthropological account of how clinical and symbolic realities are constructed during this period of learning, & how trainees negotiate these constructs within their pre-existing set of beliefs. 4. Analyse the influence of the psychiatry trainees newly constructed realities and identity on their relationship with patients, the clinic and the wider community. Method Ethnographic fieldwork in an Indian Psychiatry Department. Participant observation, interviews and content analysis of their texts will be used to gain a close and intimate familiarity of psychiatry trainees and their practices through their social and professional lives. Additionally, wider institutional forces that shape teacher-student relationship will be examined to unpack the political economies that shape the identities of mental health professionals. Outputs 1. The first post independent history and anthropological analysis of Indian psychiatry trainees, for a nation of 1.2 billion people, and implications for other low-income nations. 2. The formulation of policies and practical solutions to ensure that training and services are more culturally responsive to the majority rural Indian population who place their trust in India’s biomedical services.

Mental Health & Urban Marginality: a clinically applied anthropological study in Ecuadorian “Slums” MPhil student: Mr..Manuel Capella


Primary Supervisor: Dr. Sushrut Jadhav

The Latin American Republic of Ecuador became an independent nation in 1830. Now, more than 180 years after, the country still lacks a proper mental health legislation to guide the delivery of adequate and inclusive mental health services. Historically, formal mental health care has been a privilege instead of a right. These comprise services delivered by private psychiatrists and psychologists, that has only benefited citizens in a position to afford it and excluded those who cannot. Along with this economic exclusion, there has also been a cultural exclusion. The understanding of mental health and the practices for finding relief when facing distress varies depending upon the cultural background of each social group. Currently, there have been new political initiatives within the country, including attempts to improve mental health care. Policies, services and training in mental health ought to be predicated upon a profound knowledge about the reality of the population that they intend to benefit, especially about the lived culture of the people who have been historically excluded and marginalized. “During the last thirty years…we have not been able to position it (the matter of mental health), nor institutionalize it, nor include it in the public health agenda” (AB, Senior Health Civil Servant).

Ecuador. Population: 16.083.600 (2014 )

“There should be a center where they give us guidance…in the areas where we need it the most, in the more distant areas of Guayaquil” (CD, middle aged, female, domestic worker, lives in a city slum) RESEARCH QUESTIONS 1) Are current mental health policies and primary care services accessible and culturally congruent with the population living in marginalized zones of Guayaquil? 2) What are the social constructions of mental health and mental health care amongst marginalized people? 3) What are the social constructions around mental health and mental health care amongst policy makers and mental health professionals? 4) How can the mental health primary care system be improved, for it to be more responsive to the reality of the marginalized groups? METHOD Ethnographic fieldwork in a marginalized zone within the city of Guayaquil. Participant observation, interviews, examination of professional & popular media, and critical discourse analysis will be used to gain a better understanding around the mental health constructions produced by citizens, professionals and policy makers. A wider psychosocial approach will be used in order to take into account the social context that shapes these inter-subjective constructions. OUTPUTS 1. The first social sciences research around the inequalities on the access to primary mental health care in Ecuador, with a particular focus on the reality of marginalized groups in the city of Guayaquil. Implications for other Latin American Nations. 2. Recommendations regarding policies and training that ensure equal rights to access primary mental health, in a way that is culturally congruent and responsive to the lives of the people.

“Social Sector” Government Building in Guayaquil

A 30 minutes drive: an actual vulnerable “social sector” (city slum)

Casted minds in Higher Education in India: Caste Identities and their role in shaping Mental Well-being (2015-18) Nilisha Vashist (MPhil/PhD) Primary Supervisor Dr. Sushrut Jadhav Caste continues to flash itself in every aspect of Indian society, despite an otherwise formed consensus of its diminishing importance, especially in urban India. Higher education, in this regard , has become the center stage of caste dynamics with fierce debates on ‘merit’ often serving as pivot to orient caste relations in pedagogy. Caste identities are consolidated, negotiated and contested through everyday interactions among students, faculty and staff, in turn, shaping the psyche of actors involved. How do these constructs affect psychological well being of students situated both at higher and lower ends of hierarchy? Objectives 1. Understand how caste forges identities among students, teachers and staff. 2. Study experience, contestation and resistance to caste based academic discourses by students. 3. Assess the psychological impact of caste identities on students and devise suitable interventions to mitigate it.

Omnipresence of caste in higher education

Methodology Ethnographic fieldwork in an Indian University. Data collection through participant observation, interviews, case studies and discourse analysis of everyday interactions and dynamics of caste in the campus. Expected Outcomes 1) Linking together theoretical (medical anthropology) and applied (cultural psychiatry) sciences and the center and margins of Indian society by exploring the role of caste identities in shaping psyche. 2) Generate a pilot model of intervention to reduce caste mediated psychological distress in pedagogical environment.

Caste, pedagogy and debates on ‘merit’

UCL & BALM Dr. Jadhav, is Co-Director of the UCL- Banyan Academy for Leadership in Mental Health (BALM), Chennai programme www. Further details: , . UCL-BALM collaboration was established to examine and critique mental health care in India, and to develop knowledge, skills and competencies amongst the next generation of mental health professionals and carers. The UCL team runs annual intensive short courses in Chennai (2008-). To date this programme has trained over 170 participants: lay volunteers, social scientists, psychiatrists; psychologists, social workers, ayurvedic practitioners; and occupational therapists. BALM & UCL brings people together to consider, rethink, and develop mental health models rooted in local history and culture. UCL-BALM collaboration bridges the gap between academic theory and action on the ground, developing culturally-valid mental health theory to help those who are socially marginalised, distressed and suffering. Existing research focuses on pilot studies such as on homeless mentally ill women in South India, farmer suicides, cultural forms of engagement, and understanding the stigma attached to mental illness in India. To date, most research in Indian mental health institutions remain confined to western approaches. Understanding local deep subjectivities require integrating medical anthropology with mental health. UCL Cultural Consultation Service & Global Citizenship Through learning and sharing cross-cultural aspects of teaching in India & UK, insights gained from such activities will help UCL faculty enhance teaching and learning methods for a multicultural and diverse institution, such as UCL. Internationalisation of UCL curriculum includes the course content (e.g. syllabus, teaching methods, assessment, reading lists and research), different world views on the subject, and the global impact of the subject and ethical issues. This is in keeping with UCL’s stated policy of education for global citizenship. Recent developments such as the establishment of UCL Campuses in Australia, Kazakhstan, Qatar, etc will allow both faculty and students to seek support from expertise at the Cultural Consultation Service Future developments The next UCL-BALM short course, planned for November 2013, to be held in Chennai, India, is titled ‘Cultural Identity and Distress’. For details, contact Dr Sushrut Jadhav. We also aim to develop a clinical postgraduate degree programme with the Tata Institute of Social Sciences (TISS), Mumbai, to provide a cross-cultural, cross-national, cross-disciplinary

platform for teaching and research that links clinically applied anthropology, mental health, and psychiatric social work. We aim to upscale our series of short training courses in Chennai and to establish new research projects in areas where culture is germane to mental health of marginalised communities. By doing this we hope to reinvent psychiatry and radicalise mental health care in India, and roll out culturally sensitive mental health professionals to benefit dispossessed people who place their trust in India’s official mental health services. The TISS clinical post-graduate degree programme is expected to commence in 2014 subject to funding. UCL aims to embed an intensive 4 week module within such a programme, as part of its outreach teaching and research activities. Click here for further details on UCL-India Research and Teaching clinically applied anthropology: UCL-India research on clinically applied anthropology (see attached document for this link).


Reinventing India's Mental Health Care - UCL

UCL Cultural Consultation Service & International links Reinventing India’s Mental Health Care The problem “There is an urgent need to reinvent a new...

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