In an unequal society like India, community-led interventions can make therapy more accessible

Most health systems consider mental health therapy as an individualised form of medicine, but community mental health approaches could make therapy more accessible to people and create communities of support, some experts suggest and research shows.

A 2017 study published in The Lancet found that approximately one in seven Indians is affected by a mental health concern of varying degrees of severity. India has a suicide rate of 21.1 per 100,000 people, estimates the World Health Organization. In addition, post the Covid-19 pandemic, mental health concerns have risen across the globe.

Yet, mental health practitioners are in short supply. In India, there are two mental health workers and 0.3 psychiatrists per 100,000 population, below the global average of 13 mental health workers for 100,000 people.

Community-based mental health interventions could potentially help overcome this shortfall of mental health practitioners. In addition, research suggests that the source of mental health issues is often external, such as social pressures, or domestic violence, and therefore, community-based interventions might help more than individual therapy. Programmes in India include those by non-governmental organisations such as Sangath and the Manas Foundations that train community health workers to identify and help with mental health issues.

Distress-causing environment

Cognitive Behavior Therapy is one of the most common types of therapy practised across the globe. It is based on the premise that our thoughts about events in the external environment cause feelings about the event, which in turn affect behaviour. The therapy assumes that a change in perception of the external environment can change thoughts, thereby reducing feelings of perpetual sadness or anxiety.

This form of therapy, and other forms of psychotherapy, usually do not acknowledge the social, political, or cultural causes of distress, and are based on individualistic ideas supporting the proposition that changing mindsets in therapy can reduce individual suffering. But, Sanah Ahsan, a psychologist based in the UK at the National Institute of Health, wrote in The Guardian, that encouraging individuals to change mindsets in therapy could be another way of adapting to systems that are inefficient, and protect the status quo which harms marginalised groups.

For instance, if a person is experiencing economic hardship due to systemic issues such as income inequality, encouraging them to change their mindset and work harder to achieve financial success could be seen as a way to adapt to a system that is inefficient and unjust, rather than addressing the structural issues that create economic inequality in the first place.

The other common practice is medicalising mental health. For instance, serotonin imbalance is understood as one of the primary causes of depression and reduced dopamine has been long associated with reduced motivation. These beliefs, nevertheless, are changing now. “The main areas of serotonin research provide no consistent evidence of there being an association between serotonin and depression, and no support for the hypothesis that depression is caused by lowered serotonin activity or concentrations,” a 2022 review of studies concluded.

Medicalising mental health, and thereby finding roots of the problem in faulty brain chemistry, can also be disempowering, especially when it distracts individuals from the environment that has caused this distress. Saba Ahmed, a Delhi-based senior researcher with SEWA Bharat, a trade union of women working in the informal sector, said that often, in interactions with women from the informal economy, “a lot of the problems or concerns women express are related to the precarious nature of their employment”.

Mental health experts now understand that people in lower socio-economic communities and marginalised groups are more prone to poorer mental health outcomes. Lower levels of income, precarious nature of work and perceived lack of control in some social groups are factors that increase the severity of stress. Similarly, poor mental health outcomes are also linked to employment conditions, such as the informal sector, where a significant proportion of Indian women work, and where stress due to poorly managed systems and violence is prevalent.

Professionals should not resolve mental health concerns by counselling over the telephone or by using pills, when the concerns are due to discrimination, physical assault and lack of basic necessities, such as food and shelter, wrote Sudharshan R Kottai, a psychology professor at Jain University in Bangalore in an article in the Economic and Political Weekly. He argued that mental health professionals often understate socio-political factors that cause distress.

“One of the first reminders I instil in my practice and therapeutic work is the reality that therapy can sometimes be a space to process systemic distress,” said Sanjana Kishore, a counselling psychologist based in Bengaluru. “Often, clients come in with concerns that cannot be resolved by just individual self-work because their worry is being caused by very valid community – and system-based difficulties, such as discrimination, financial instability, lack of community support, etc. In such cases, acknowledging the external nature of these worries and not letting the client attribute these difficulties onto their own self is the cornerstone of any therapeutic work done in the session.”

Community health approaches change the emphasis of mental health interventions from “a remedial, to a preventive one”, and aim to build communities that can decrease the prevalence of mental health concerns, writes EJ Trickett from the University of Maryland, in The International Encyclopedia of The Social and Behavioural Sciences.

Having social support groups or solidarity networks within close-knit communities to interact with, especially in times of crisis, can help people find a sense of belonging and support, reducing prevalence of mental health concerns.

Decentralising health services

A 2018 study by The Lancet found that suicide death rates are higher in India compared to the global average, especially amongst women from lower socio-economic classes. Depression rates were higher in women than men – across age and geographical locations. According to the 2015-’16 National Mental Health Survey, women are more vulnerable to certain mental health concerns, such as depression and other stress-related disorders.

While some private companies and public sector enterprises devise ways to promote the mental well-being of their employees, 91% of India’s female workforce works in the informal sector, and are devoid of mental well-being initiatives. Further, they are discriminated against on equal pay, work in hazardous environments, and are prone to sexual and physical exploitation, all of which has the potential to increase stress.

During the pandemic, instances of domestic violence also reportedly increased, as did young people’s mental stress as they manoeuvred school and university closures and social isolation for prolonged periods.

Decentralising health services can make them more accessible. Women who have received decentralised health services through teleconsultations organised by SEWA have reported easier access to the larger health infrastructure. In absence of such programmes, women report facing several challenges. For instance, one of the programme beneficiaries, a middle-aged home based worker in Delhi, noted that “going to the hospital is difficult because it takes a lot of time to travel, and requires changing means of transportation multiple times and can take up the entire day”. Often, because of the nature of the work, paid leaves are inaccessible.

Further, when it comes to mental health, lack of awareness about where to find doctors, or mental health professionals adds to the existing problem. Another, home-based worker from Delhi, said, “My husband is an alcoholic and wastes all my money on his indulgences; I really wanted to do something, wanted to save my money, if not him. I didn’t take him to any doctor, I didn’t know where I could find one.”

Local groups, or community leaders who are present nearby, could also provide support when other experts are unable to be on the ground, said Aakanksha Bhatia, psychologist and founder of MannRaahi, an organisation that aims to empower teachers and students in schools to co-create safe spaces for mental health. “While support groups facilitated by experts can be useful, they require experts to be physically present on the field which became challenging due to Covid-19. Peer leaders or psychological force-aid teams present on the ground can therefore prove to be more helpful in such times.”

SEWA-trained community leaders, during the Covid-19 lockdown, when the existing health infrastructure was overwhelmed, helped. A domestic worker from Delhi, who did not want to be identified, said that “having someone I trust (the community leader within the area) who connects me to a doctor over the phone for reliable medical advice helped our family navigate the uncertain times without having to go out and be turned away from the hospital”.

Community-based programmes

Community mental health approaches have shown promise – and could perhaps serve larger groups of people better. Atmiyata, a community volunteer service in Gujarat, has reduced the prevalence of mental distress, through volunteers who raise awareness about mental health and identify prevalence of distress and facilitate referrals to the Primary Health Centre. Larger scale evaluations of the programme are ongoing.

Similarly, the Manas Foundation leverages the support of community health workers (such as Accredited Social Health Activists and Auxiliary Nurse-Midwives), and builds their capacity to identify mental-health related concerns to integrate mental health with other primary care services.

Another organisation, Sangath, has several ongoing programmes that aim to increase community-level awareness, that train people in the community, such as health workers who function as lay counsellors, to address mental health concerns. There were positive effects on the mental health of adolescents who were part of a programme where lay counsellors were trained to provide assistance to adolescents from low-income groups in Delhi.

Community groups can identify individuals with deteriorating mental health and link them to larger health infrastructures, explained Bhatia of MannRaahi, who is also a former professor of psychology at Delhi University. She suggests collaborations between the public and private sector to enable such interventions to become large-scale so that they can impact larger groups of people.

While talking about the efficacy of the programmes at MannRaahi, Bhatia noted that students who are part of their programmes, such as Social Emotional Learning, Mental Health Literacy in classrooms and Family Partnerships programmes, had greater mental resilience, an ability to help out their peers when they are in psychological distress, and an improved sense of self-efficacy and esteem in students, which is evident from their conversations and their capabilities during sessions and activities.

Community-led mental support

“The vocabulary to identify a mental health concern is often missing within grassroots communities, like communities of women working in the informal economy,” said Saba of SEWA Bharat. “Treating larger systemic issues as women-centric issues also exacerbates the problem. Depression, for instance, may affect a greater proportion of women than men but is still a community problem because the mental health of the woman has the potential to impact the entire family and even the community that she is a part of.”

How a community-led mental health intervention is designed is also important, experts said.

“Each community is different, and has a different context, and therefore what works in one area may not necessarily work in another,” said Bhatia. “Therefore, building community-level programmes, with culturally specific and tailored interventions which involve community or peer leaders as a psychological force aid, can be helpful.”

“Individuals across cultural groups are different in the way they understand mental health concerns. Therefore, it is essential that the problem, as well as the solution to the potential problem, is co-designed with the target groups,” added Yaqoot Fatima, a principal research fellow at the Faculty of Health and Behavioural Sciences at The University of Queensland.

Additionally, she noted that, moving away from the “deficit” discourse which focuses on problems and shortcomings within cultural groups and moving towards a strengths-based approach, where strengths are focussed on, can improve community-level outcomes. This approach is particularly helpful in schools where noting the positive traits that children possess facilitates positive behaviour change.

This article first appeared on IndiaSpend, a data-driven and public-interest journalism non-profit.