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.
http://newindianexpress.com/education/edex/article1307855.ece
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, http://www.sciencedirect.com/s Jadhav & Barua (2012):
UCL & Banyan
Academic for Leadership in Mental Health
cience/article/pii/S1353829212001268
UCL GRAND CHALLENGE OF
GLOBAL HEALTH
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. http://balm.in/html/ucl_balm.html
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
2014-17
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:
<http://balm.in/home.html>, <http://www.balm.in/doc/UCLBALMResearchUnit.pdf>.
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).