The IPH model of Mental Health Care

Background: Mental Health in India

The medical compendia of ancient India are replete with references to mental health covering a spectrum of diagnoses, classification and treatment methods. A description of insanity dating back to 1500 BC exists in the Atharva Veda, the most ancient authentic Indian medical scripture. Descriptions of conditions similar to schizophrenia and bipolar disorder appear in the Vedic texts; these texts differentiated doctors practicing magical medicine from scientific physicians and surgeons, who lived and practiced in cottages surrounded by medicinal plants. An ancient textbook of Ayurvedic medicine, Therapeutics and Surgical Practice by Charaka and Susrutha, has a vivid description of schizophrenia. It states clearly that only an expert in the field of mental health should treat people with this illness.

The cause of these disorders, in Ayurveda, one of the oldest Indian medical systems, was thought to be endogenous. Exogenously the causes were attributed to sudden fear or association with ill influence of certain mythological gods or demon,

Treatment of mental disorders used to be in the form of talismans, charms, prayers & sleeping in temples with rituals. It included 'shock' in the form of terrorizing the patient by snakes, lions, elephant or men dressed as bandits. Drugs included substances such as Cordfolia, horse radish, asafetida & rock salt, centella Asiatic, catechu, honey, etc,

The Unani system is known to have described seven types of mental disorders in 1222 AD which included Schizophrenia, depression, delusion of love, Organic mental disorder, paranoid state & delirium.

The Siddha system formulated a treatise on mental diseases in which 18 psychiatric disorders with appropriate treatment methods is described.

Historical records indicate that during the reigns of King Ashoka, many hospitals were established for mentally ill.

Modern psychiatry arrived in India only with the British rule. The first lunatic asylum was built in modern India in approximately 1750 AD. In 1794, a private lunatic asylum was opened at Madras. The central mental hospital in Pune was opened in 1889 while the first asylum for insane soldiers was started in Bihar in 1795.

The Lunatic Asylum Act 36 of 1856 was modified to form Indian Lunacy Act, Act 4 of 1912. The enactment of act resulted in opening of new asylums and improvement in the condition of asylums. The name lunatic asylum was changed to mental hospital in 1920.

With the advent of 'modern psychiatry' as a part of the British rule in India, both these systems of dealing with mental illnesses started functioning in tandem. The collection of Indian systems was in a way more holistic but seemed to lack the 'scientific edge' of the western system. These systems were (and in many cases still are) the first choice of treatment for most Indian people possibly due to their inclusiveness, & because the populace then had a skeptical view of almost everything British. The western system brought in by the British was more scientifically based but was focused exclusively on treating the ill & doing so by segregating them from the social mainstream - confining them in asylums.

In 1946, it was recommended that changes be made in Indian Lunacy Act 1912, as it had become outdated. However, the 'Mental Health Act' was not passed till 1987. Since its coming in to force, it is yet to be fully implemented in several states in India.

As a result, the focus of the state sponsored mental health care is still, largely, mental illnesses & their treatment through a medical clinical model. The model has fostered passivity and dependence in the help seeker while the professionals have been personally isolated, cold and out of touch with changes the patient is experiencing. The physical setting of treatment has been sterile and threatening & the treatment methods long and nurturing passivity.

In a sense, the reforms which swept across the mental health field in the first decades of the 20th century never completely percolated to India. Mental health continued to mean (and to a large extent still does mean) treatment of mental illnesses. Mental health, defined as a state of well-being in which every individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community, never seemed to reach India!

Conceptualization of IPH

In the early 1980s when IPH was first thought of, mental health was very much a zero priority sector for the government. The reasons were probably understandable - the Indian society was in a way 'secure' wherein, economic liberalization had yet not begun, cable television was yet to arrive, the IT revolution had not begun - in a sense, most the populace led largely content lives & didn't have much in terms of economic or lifestyle aspirations.

So stress levels were manageable for a majority of the society & as a consequence, the percentage of people with 'mental health problems' which had a potential of becoming disorders was also limited.

As a result, the mental health professionals largely needed to deal with people with disorders - for which they had been trained. The focus on rehabilitation as well as prevention was understandably less.

Two factors then seemed to prompt the conceptualization of IPH

With these two factors in mind, the concept of what IPH needs to be emerged. We envisaged it as a place which would focus on

Unfocussed versus comprehensive

To start with, we had a choice - be focused on a specific area or be unfocussed & provide more comprehensive facilities. For us, the choice was clear - if we intend to build awareness & reduce stigma, we need to provide an entire gamut of services so that the consumer realizes that mental health is not only about mental illnesses but also about seeking services in the other areas.

Our belief was that if we provide services that focus on prevention, growth, & rehabilitation, people would seek services even related to treatment of disorders more openly - because they would discover that mental health is not just about 'treating madness' but also about learning to deal with daily stresses, learning to improve relationships, learning to help a child with a learning difficulty & so on.

So the choice for us was clear - be unfocussed (or should we call it comprehensive?) & we are seeing the results of this gamble - IPH has been able to help at least a thousand new families every year with several more people coming for follow-up. Most of our clients for at least the past 10 years now, have been self referred and for them, mental health has not just been about treating disorders but also about dealing with stress, effective parenting, vocational guidance, and a lot more!

Focus on destigmatization

We also believed that another way to reduce stigma would be to involve the community that we serve actively in our work.

The journey to this end started with our community programs which had a dual purpose to start with - make our community aware about the breadth of mental health & second to inform people about the services available at IPH.

These programs possibly led to the lowering of barriers of stigma as it led to people wanting to get involved in our work. These people started working in our programs & activities as volunteers - initially helping out in organizing roles.

Gradually, we have managed to develop projects which are run entirely by volunteers. These include our telephonic helpline Maitra, our mental health awareness project Manovikas, adolescent sensitization program Jidnyasa, & several more.

The obvious next step was to empower these volunteers to manage these projects on their own - a task which they have been doing for at least a decade now with minimal inputs & support from the professionals working in IPH.

So they model has evolved over the years

Making a social mark

As noted earlier, we understood right at our inception that focusing only on disorders and their treatment would not help us to reach out & gain acceptability from the community and also would not help us to deal with the stigma that we sought to reduce. So for us, the concept of 'care' has always been:

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Uniqueness in implementation

Apart from the unique strategy we developed to devlop awareness, reduce stigma, & to increase the involvement & participation of our community, the uniqueness of the IPH model is evident in several other areas of functioning. To illustrate a few,

Teaching
Due to the large number of families seeking help from us, IPH has become a place for learning for many mental health professionals. There is always a continuous stream of observers & students, not only from this country but also from abroad. IPH is recognized as agency for post-graduate training & field-work by several post-graduate schools in the state including: Mumbai University, Tata Institute of Social Sciences, SNDT Women's University, Nirmala Niketan College of Social work, Karve Institute of Social Work.

IPH also has a independent arm looking in to teaching and professional development. This arm - Aakalan - conducts training programs for mental health professionals (including young psychiatrists, psychologists, & social workers); as well as continuing medical educations programs for practicing professionals.

Research
IPH has always had the advantage of having experts in both research methodology and psychology as a part of its team. The independent research cell, apart from handling in-house research projects, also provides the same services to Students, Researchers, Institutions, and industrial houses.

It has been able to provide end-to-end research solutions to the target audience & the services have included help in planning research studies, development of assessment procedures & instruments, assistance in implementation, statistical analysis, & assistance in understanding & presentation of results.

Team
The uniqueness of our model also extends to composition of our team. We have a comprehensive team of 'Mental health Professionals' which includes: Psychiatrists, Psychologists (Clinical, Counseling, Educational, Industrial), Social workers, Remedial educators, Occupational therapists, & Speech therapists.

The rationale for the multi-specialty team is quite practical - if we seek to work in so many varied areas, we need the specialists. Secondly, it also gives our clientele an opportunity to access holistic & complete care under the same roof.

IPH's work culture is marked by another unique feature - the team members & the organization go through a process of 'selecting each other.' Individuals seeking to be team members & the organization go through a period of understanding each other - those who seem to 'fit the bill' stay on. This has helped in development of a team of like-minded & dedicated professionals who have a high degree of professional competence but who at the same time can work in a flexible, open environment, provided by the organization.

It also has helped in fostering a 'Learning' culture in the organization wherein, the team gets regular opportunities for development & training - both professional & personal. Peer consultation & counseling is encouraged & nurtured as a part of this process.

The large numbers of volunteers who manage IPH's projects (more than 300 and counting) have well defined tasks, receive continuous training, have been empowered so as to run projects with minimal dependence and find their work on their respective projects to be an enriching experience - satisfying their esteem needs.

In sum, we believe being a 'Family' and being 'Professional' can be made complimentary & have succeeded in doing it to a large extent.

Finance
Clients seeking help from IPH are charged according to their socioeconomic status and charges, as a whole, are less than those charged by people in private practice.

Funds are generated from industrial & community programs and render us financially self-sufficient and facilitate subsidizing. We usually generate enough funds to manage everyday functioning & some savings and so donations & funding are welcome but never been dependent on those.

Today and tomorrow

IPH is looking at expanding the existing model to a rural campus wherein facilities for residential halfway home will be available. The campus will also try to extend the IPH model to a more rural community.

Management principles and social enterprise

IPH is technically, a NGO - a non-governmental organization. In the Indian context, these are social organizations working for social service, working not for profit & usually dependent on governmental or other sources of funding.

Ideally such organizations have the potential for individual and mass development and a potential to mould the social value system towards betterment.

However, in practice, most of the 'typical' Indian NGOs have shunned themselves from use of management principles. In fact they take mismanagement as a permit or brand identity of social work. It has, to an extent, reduced NGOs to a culture of amassing money in whichever way and thus going close to being called as bootleggers.

IPH has chosen & tried to be different & prefers to be a 'social enterprise. Designing a dream is as important as having a dream. And for designing one need management principles - which are generally criticized by social workers because of the perception, that whenever there is a system, it has to be rigid. Actually a system is a system and the users and designers make it flexible or rigid. Right from designing an event to financial discipline, most social work organization either rationalize their lacunae or go in to denial - saying that they just don't need them.

At IPH, being a social enterprise, we believe that we need not return the `money' but can return by creating manifold wealth; Wealth in the form of ideas, individuals, teams, and systems. Our balance sheet is not just about money but also consists of the credit & debit of rational & irrational attitudes / beliefs / practices in the society. And the wealth we seek to create is rational attitudes which can help in individual & collective development - in his/ their chosen field of endeavor.

We are also seeking to create a system by which the same set of beliefs can continue to flow even after the first propagators take exit.

We, therefore, do not shun away from the word enterprise - only because that phrase is not often used in the social field.