Seeking a paradigm shift in mental health care

(Mains GS 2 : Issues relating to development and management of Social Sector/Services relating to Health, Education, Human Resources.)

Context:

• Recently, a High Court suggested that homeless persons with health conditions be branded with a permanent tattoo, when vaccinated against COVID-19, since tracking a ‘floating population’ may be cumbersome.
• Earlier judgments have also suggested ‘round ups’ of such persons to facilitate pathways into care.
• These are possibly well-intentioned directives, but what follows is that bewildered persons are huddled in a vehicle and admitted into shelters or mental hospitals that are usually crowded, yet lonely.

A responsive care system:

• Persons with mental health conditions need a responsive care system that inspires hope and participation without which their lives are empty. 
• In many countries, persons with severe mental health conditions live in shackles in their homes, in overcrowded hospitals, and even in prison. 
• On the other hand, many persons with mental health issues live and even die alone on the streets.

 The mental health systems narrative:

• Far-sighted changes in policy and laws have often not taken root and many laws fail to meet international human rights standards.
• Many also do not account for cultural, social and political contexts resulting in moral rhetoric that doesn’t change the scenario of inadequate care.
• Society’s responses are often based on conditioning and perceptions, often verging on visceral forms of prejudice.
• This results in an “othering” of persons who seem different from dominant groups.
• Hence, even well-intentioned judgments could set off unintended negative, even grave, consequences.
• There is also the social legacy of the asylum, and of psychiatry and mental illness itself, that guides our imagination in how care is organised.

WHO’s key guidance:

• Society needs to understand that not all mental health conditions are associated with disadvantages, therefore, not all distress can be medicalised.
• Recently the Guidance on Community Mental Health Services was launched by the World Health Organization.
• The Guidance, which includes three models from India, addresses the issue from ‘the same side’ as the mental health service user.
• Guidance focuses on the co-production of knowledge and on good practices built around the key themes of crisis services, peer support, supported living, community outreach, hospital-based services and comprehensive mental health service networks.
• Drawn from 22 countries, these models balance care and support with rights and participation.

The evaluation of services:

• Atmiyata in Gujarat employs a stepped-care approach using community-based volunteers who identify persons in distress, offer counselling support and enable access to social care benefits.. 
• Naya Daur in West Bengal works with local networks and volunteers who support homeless persons through their outreach programme and enable access to food, clothing, counselling, shelter and housing. 
• A programme of The Banyan in Tamil Nadu, facilitates residence options in regular neighbourhoods while also offering graded levels of supportive services for persons with severe disabilities.
• It emphasises socio-cultural participation, ‘neurodiversity’ and normalisation of mental health conditions.
• Peer leaders provide wisdom from their lived experience to support others in distress.
• Evaluation of the service indicates better general health, better quality of life and social functioning

Open dialogue practice:

• The practice of open dialogue, a therapeutic practice that originated in Finland, runs through many programmes in the Guidance. 
• This practice, conducted in homes or in service settings, combines individual and systemic family therapy with a focus on the centrality of relationships and promotion of connectedness through family and support networks.
• This approach trains the therapist in de-escalation of distress and breaks power differentials that allow for free expression.

A network of services

• Recently, the Supreme Court and the Madras High Court have advised vaccinations for those in mental health care homes and for those homeless and living with a mental illness. 
• While those in institutions should access this support at the earliest but for those homeless and who opt not to enter mental health establishments is quite difficult.
• For the homeless, provide a network of services ranging from soup kitchens at vantage points to mobile mental health and social care clinics, non-intimidating guest homes at village panchayats with access to toilets and well-being kiosks that offer a basic income and/or facilitate livelihoods.

Value diversity and social mixing:

• Small emergency care and recovery centres for those who need crisis support along with long-term inclusive living options in an environment that values diversity and celebrates social mixing is needed.
• With a strong health system, Tamil Nadu demonstrates that an exclusive policy for homeless persons with mental illness, political intent, good governance and creative thinking can solve complex problems and cater to the needs of the ultra-vulnerable.

Conclusion:

• Aimed at providing newer perspectives to governments and policymakers, approaches in the new WHO Guidance are designed to make community inclusion and dialogic practice a way of life.
• Meanwhile, if we can learn to ‘be on the same side’ as the mental health service user, it seems possible that we can learn to respect human diversity.