Of the Indian populace 70 to 90% does not have access to mental health treatment and care. It is safe to say that these services are disproportionately available in urban areas. The mental health care system in rural India has all the shortcomings and failings of India’s rural physical health system.
The shortcomings include an insufficient number of trained health care providers, poor quality of available services, the need to travel long distances to avail of any service, and the exorbitant costs. The National Mental Health Survey of India 2015-16 estimates that a person accessing mental health care spends Rs 1,000 – 1,500 per month on travel just to access mental health care.
Adding to the psychosocial stressors for rural communities are multiple barriers to accessing education and social benefits, besides shelter and livelihood vulnerability due to the vagaries of climate. The treatment gap construct has a biomedical focus.
Treatment gap is the difference between the number of people who need mental health care and those that get treated, generally expressed as the number of psychiatrists available per 100,000 people. It is inadequate for addressing these challenges, and exploring solutions for rural mental health.
Mental health issues are clearly linked to the psychosocial sphere, and can adversely affect participation in everyday activities. It is important then, to go beyond a ‘symptom reduction approach’, which is a medical therapy aimed at the symptoms and not the underlying cause. It is important to work towards social inclusion via multiple pathways – such as employment, skills training, community education and community support.
While the prevailing treatment gap model erases this range of interventions, the mental health care gap construct combines the treatment gap approach with psychosocial care interventions. It also takes on board physical care gaps and needs of those living with mental illness.
Recently, World Health Organization recognized Atmiyata as one of the 25 good practices for community-based mental health services around the world. The model develops the capacity of two tiers of community volunteers, to identify persons with emotional stress and common mental health disorders, and provide them with primary support and counseling. They make referrals to the public health system in instances of severe mental illness.
A rural mental health program called Atmiyata is in practice in Mehasana district, Gujarat. Atmiyata translates as shared compassion. Currently run by the Centre for Mental Health Law & Policy (CMHLP), a non-profit organization, Atmiyata employs all the strategies mentioned earlier.
Training local community members to serve as a resource for community-based support is a key component of Atmiyata. The project has two tiers of community volunteers, namely, champions and mitras (friends). To be a champion, the person has to be a leader of a self-help group or farmers’ club, be good at connecting with people, and have a good insight about his or her own community.
Those who are willing to spare time for training and take pride in helping others are chosen to be champions, given that the program has a non-monetary recognition. Though not mandatory, those with basic literacy are given a preference. The idea of having another tier of volunteers called mitras emerged during implementation, as an additional support to the champions.
A psychiatrist, assisted by behavior change specialists and NGO staff with prior experience in rural development, trains the champions. The 7-day training has a mix of theoretical and practical sessions, ranging from classroom-based lectures, film screenings and interactive discussions to role plays. The role plays teach champions how to use symptom cards, and practice counselling with community members.
Also, they get trained to facilitate social welfare benefits for community members. They learn how to use the Mohalla Mapping tool in the field to map distress in their communities. This training is enhanced by follow-up and supervised site visits every two weeks.
Addressing the issues
In order to reduce stigma and create awareness about mental health and well-being, both sets of volunteers work with existing self-help groups, farmers’ collectives, village chiefs, village panchayat leaders, anganwadi (child care center) workers, accredited social health activists (ASHAs), primary health center staff and others who are trusted and respected in the community.
CMHLP has given smartphones loaded with the Atmiyata mobile application (app) to Atmiyata champions. The app contains training materials as well as films meant to build community awareness about everyday social distresses: domestic violence, alcoholism, unemployment, spousal conflict, etc.
The films can be shared via Bluetooth, encouraging wider discussion and helping de-pathologize the subject of mental health. This focus on psychosocial stressors, common causes of distress versus the biomedical approach is critical – whether in trainings, providing services or the type of language used.
The Atmiyata champions’ interventions include evidence-based, low intensity counseling techniques such as active listening, problem solving, and behavioral activation. Behavioral activation helps a person to reflexively look at daily activities and behaviors, and plan to engage in purposeful activities. It is a therapeutic intervention that is often used to treat depression, in addition to helping us understand how behaviors influence emotions.
They are also trained in facilitating villagers access social benefits such as pension allowances, disability benefits and unemployment benefits, besides providing information about social benefits available for caregivers. 1,491 families have been linked to social benefits and welfare schemes before the start of lockdown in March 2020. In cases of domestic violence and substance abuse, they make referrals for legal aid, shelter homes and employment.
Atmiyata mitras, the second set of volunteers, has a different role. They work towards identifying people with mental health problems and reducing stigma that surrounds mental health. They also build their community’s understanding of mental health.
For persons who might require further help, Atmiyata leverages the District Mental Health Program by facilitating referrals to public health care facilities and district hospitals, as well as to relevant district authorities in the public health and social justice system. 2,541 people with severe mental disorders have been referred as of March 2020.
The intervention has reached out to 525 villages, covering 0.8 million adult population, as of March 2020. More than 16,500 people have been counselled for common mental disorders. With the support of more than 500 champions, the intervention continues to expand its coverage, especially to reach out to marginalized and vulnerable communities.
Atmiyata is premised on the tenets of community-based mental health being in practice for some decades now. It shares similarities with other programs – like the Goa-based MANAS that trains rural community mental health workers to work alongside primary care physicians and mental health specialists; and The Thinking Healthy Program used in rural Pakistan where trained primary health workers address post-natal depression.
Yet Atmiyata has some distinctive features: the mitras are informal caregivers from the community. They are not primary health workers – an aspect that moves away from task-shifting (redistribution of tasks among health workforce teams), and re-delegates specific care services from highly qualified health workers to those with shorter training and fewer qualifications.
This allows for a high level of intervention by mitras who have a close connection with the social fabric of the place, share the living circumstances of persons needing care, and are able to communicate about mental health using context-specific and accessible language.
The program is distinctive in its use of low-cost smartphones to enhance learning, build awareness, record feedback, and evaluate psychosocial interventions. Such recorded evidence helps us look at scalable models of community mental health, and also helps discover better ways than the treatment gap model. It helps to articulate more relevant approaches to the complexities presented by mental health care gaps in rural India.
Additionally, Atmiyata’s reliance on informal care by trained volunteers from the community lowers program costs, and helps in building trust. It effectively means that communities work to support their own members, thereby increasing community cohesion and resilience. Community stakeholders being involved and centered in the training and evaluation processes enriches the program, and offers a sense of community ownership.
The Atmiyata program provides community with primary, secondary and tertiary care, even as it harnesses the public health system for specialized care. The underlying principle is that, it is more cost-effective and sustainable to strengthen these public services than to turn to private or other expert-led services, as the public health provisions are mandated by law.
The champions and mitras use a well-established referral chain, and carry out follow-ups with psychiatrists working at the district level. This ensures timely diagnosis of mental health issues, and adherence to treatment in case of severe mental illnesses – thus bridging the gap between the shortage of trained mental health professionals and unmet mental health needs in rural India.
Raj Mariwala, with an educational background in business economics and international relations, is Director at Mariwala Health Initiative. Raj serves on the boards of various national and international organizations. Views are personal