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Nov 17, 2010

People to People Delegation to India

11/16/2010 Delhi, India-MORNING:
We met at IHBAS with Professor (Dr.) Nimesh G. Desai, MD (Psych), MPH, MRC Psych director, Institute of Human Behaviour & Allied Sciences (IHBAS) and his staff for 3 hours. This was followed by a tour of IHBAS. Dr. Desai is very well-liked and respected by students and colleagues alike—every ten minutes or so, there were students and colleagues who came by to say hello to him and shake his hand!

December 2005-Indian Disaster Management Act (NDMA)—chaired by the Prime Minister himself—group setting up guidelines re: disaster management
Dr. Desai was the only representative regarding mental health—he kept pushing for guidelines regarding psychosocial aspects of disaster health management—October 2010—manual released, spearheaded by Dr. Desai, regarding guidelines re: disaster mental health policies—this document will be the main focus of our People to People discussion.
While we were in Dr. Desai’s office, he was such a very gracious host! During our official meeting, we were served tea and coffee, cookies, cake, and snacks!
There is more active interest these days in mental health in India; there is recognition to address the needs of mental disabilities. There is still work being done to quantify mental disabilities (IQ, etc.).
India Psychiatric Society developed an instrument –IDEAS—used to assess adults and has been in use for 6-8 years; are looking at updating the instrument—diagnoses schizophrenia, bipolar, obsessive-compulsive, and dementia—more similar to our MMPI. The delegation also discussed cultural perspectives regarding assessment, balancing cultural meanings with the robustness of the instrument.
There was discussion about the cultural distinctions with the first mental hospital (when India was under British rule); how there was once a separation and distinction—essentially two mental hospitals—one for Europeans and one for natives. In the years that followed, hospitals grew—1920’s (more custodial). After World War II, treatment became less custodial in mental hospitals; there was increased growth in psychiatry units. In 1960’s, more psychiatric hospitals developed.
Since 1974, Banglor has catered to medical health and surgical health needs in combination. This hospital is the modern model of this integrated treatment history. IHBAS has operated on the theme: “brain-mind problems and their solutions”. It is an institution that is a combination of mental health and neuroscience. A similar one to this still exists in Banglor—this one and the one in Banglor are the only two.

This hospital was started in 1966, as a mental hospital. In the early 1990’s, there was a push for this hospital to become not just a mental institution, but also a research and academic organization. He was appointed director this year (seven months ago).This is a part of India’s National Mental Health program.
It has a 350-bed impatient service and 800 people are seen on an outpatient basis daily; of which 10% receive first-contact care. IHBAS has a very active outreach service for the city/state of Delhi. Mental Health Interview Services; have started a program with IHBAS for outreach to the homeless populations. Not much Axis II homeless; mostly people function at work every day. There is, however, a portion of the homeless population that suffers from mental illness (schizophrenia , bipolar).
One of the outreach programs works on the street in conjunction with the legal department and a judge to write treatment orders for people right there on the street. Program activity happens on Monday evenings. The program seems to be working well so far. This is one way that this is further integrating mental health services in the country.
India is still working to break the social stigma of mental illness in general (as we are at home), but there is positive effort toward social change. Access to care is a lot more active than before. Mental institutions still have some stigma—the integration of neuoroscience and mental health under the same roof (with this model) were created in the 1970’s to reduce this stigma. Also one in Danghi like this; the other 39 mental hospitals in India are in different stages of reform.
Psychotherapy/counseling practice is variable. It gets practiced more in the private sector (with those who can pay); some outreach is done and funded by the government of India to reach other populations who cannot pay, but is still somewhat limited. Often social workers and nurses help to address needs in outreach settings.
This hospital does training in psychiatry, clinical psychology; a masters’ program in social work will be coming soon.
There has been discussion over the years about whether the western models of psychotherapy (in the US or UK) are applicable to Indian psychotherapy practice. This discussion began in the 1970’s. There is still discussion in psychotherapy and counseling realms about what can work best for Indian populations in terms of psychotherapy. The focus in training in India is often not focused on psychotherapy in counseling; there is less of a social context (more of a focus on psychopathology.
In terms of counselor training, more of just an orientation to the basics of counseling—working with a particular type of client (family work, domestic violence, HIV victims’ counseling, and disaster mental health.

India offers more flexibility with practicing mental health; people from other countries can come in and practice often with the licensures they have. We discussed the change in the US to a more holistic wellness model, and also the movement toward social justice, integrating work with the public health and social work models.
Report on one-year pilot study completed after an earthquake in India in 2001. It is about going into disaster situations with a normalcy paradigm—looking at survivors as individuals who are expressing a “normal response to an abnormal situation.”
Major disaster—Bopal, Dec. 1984—really made the country examine its disaster response strategies. It was the beginning of such work—no experience in terms of looking at “disaster mental health” at that time. In the 1990’s, up to 2004, more experience with disaster mental health response grew. These have really shaped the knowledge in terms of disaster mental health.
Dr. Desai gave us each a copy of India’s Disaster Mental Health Guidelines, which can be shared with our colleagues in the United States (Dr. Desai gave us permission). Disaster mental health in India is an area where India is able to share a lot of expertise with other countries, due to what they have learned in response to experiences. The Indian communities have really developed strength in terms of disaster mental health resilience. (It’s not only about managing PTSD symptoms—it’s so much more complex than just more training in PTSD!)
We also talked about the ethnic social-cultural aspects of the need to address disaster mental health response in the way that is comfortable for the local populations. We also talked about Hurricane Katrina in the US (Dr. Desai has also been doing a great deal of reading about Hurricane Katrina as well).
Looking at the situation in Gujarat with the perspective of “normal response to an abnormal situation” as opposed to looking at this with a pathological (psychiatry) “lens,” it was much more beneficial for the people and helped them develop more resilience in the context of the situation. There is, however, the need for maintaining some direct mental health services in disaster (for people who need treatment for psychological conditions that existed prior to the disaster). It is also important that secondary and tertiary mental health services are running well for effective disaster mental health service delivery.
Conference on Disaster Mental Health in India in 2003—what do we know, what do we not know?
Spirituality also played an important role in disaster mental health recovery in community. Listening to the victims of the disaster tell their story is also very important. Having to look at the needs in terms of Maslow’s Hierarchy of Needs framework, in terms of what community members think is important (food to eat, a place to sleep, etc.), especially in disaster situations. Make sure basic needs are met first before disaster mental health needs are addressed.
Dr. West-Olatunji shared that India has provided an excellent model of community-based mental health response. Other countries would do well to develop innovative ideas about disaster mental health response (India is helping to lead the way in this area!).
We also were a part of the World Epilepsy Day recognition ceremony held on the facility’s grounds. Local students performed a skit to communicate the message that the best treatment for epilepsy is with the help of good doctors.
In combination with medical treatment for patients at IHBAS, there is a focus on integrating family-based support with the treatment of the individual. We received a tour of the facility, guided by Dr. Desai, the director, as well as Dr. Krishna Vaddiparti, Dr. Vjender Singh, and Dr. Deepak Kumar. We also met many other doctors who work with patients at the facility; they also took part in the World Epilepsy Day celebration on the campus. As part of the celebration, they organized games and contests, as well as the skit, to bring the community together for a celebration of community outreach with families. We had lunch with the entire staff of the hospital, as well as some members of the community (families who are part of the hospital’s outreach community. We were touched by Dr. Desai’s connection with patients and families. Even with all of the demands of his job as a hospital director, working in community outreach, and being part of disaster mental health response and research in India , he hosted all of us.
The next location we went to was AADI—Action for Ability Development and Inclusion. There we met the Executive Director, Syamala Gidugu, and Anita Lodhni who are in charge of research for the AADI. We also met Shweta Verma, who is the Program Coordinator of Advocacy and Inclusive Development for SAARTHAK ( a disaster mental health NGO). We sat and learned about the history and services at AADI and asked questions about their service delivery. They serve over 2000 clients per year plus their family members and have about 100+ staff members across several disciplines. Much of their work is outreach to schools, families, and communities. They also take time to educate the corporate sector about the need to treat those individuals with physical disabilities as they would anyone one else. The staff also spends time with teachers to foster inclusion practices in the classroom.
The meeting ended with a question and answer period and an exchange of business cards.
During the return home, we saw cows walking along the city streets and sidewalks. The roadways were filled with all kinds of vehicles: bicycles, pedicabs, cars, buses, and vans. The weather was still warm with low humidity, although the sky had been overcast all day. Because several of us have not received our luggage, we went to the mall next door to the hotel and purchased emergency clothing. This was followed by a relaxing dinner in the hotel where there was lots of activity as the hotel was the location for a local Indian wedding.
Tomorrow is a Muslim holiday but our meeting hosts have committed to spend time with us anyway. We are looking forward to another day of excitement…

Cirecie West-Olatunji, Associate Professor, Mental Health Track Coordinator Counselor Education at the University of Florida and ACA Governing Council Representatitve, is leading a People to People Disaster Mental Health Delegation to India. She will be sending us regular updates during her trip.

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