Context is crucial for one to understand the experience of the other and empathize with them. As the field of mental health gains more attention, research, and resources, it is important to evaluate how it is being adapted and accepted in different parts of the world.
Mental health concerns and illnesses are often described as individual experiences. While each mental health concern may manifest in unique ways, there are certain common experiences one can locate in them. Diagnostic and Statistical Manual of Mental Disorders (DSM) developed by the American Psychological Association (APA) grouped different mental health concerns according to observed and reported symptoms. Categorisation in this way helped in diagnosis and treatment for mental health disorders. However, this categorisation and treatment method when adopted in Asian countries, was not easy. Barriers to mental health care including stigma, resources, affordability, and accessibility become crucial in low and middle-income countries.
Understanding Marginalisation in Mental health
Therapy and treatment of mental health disorders in the West focus on individualized healing, diagnosis, and experiences. The emphasis on the ‘individual’ does not acknowledge the systemic inequalities in society. For example, in 2018, India reported 17% of the suicides in the world. While suicide may be comorbid with other mental health problems, it is necessary to recognize the systemic inequalities that contribute towards it. Marginalization, lack of access to mental health resources, poverty, and lack of social support faced by farmers, violence against LGBTQIA+ people, victims of rape are factors that contribute to suicide. When focusing on individual suffering, trauma experienced by the collective is often not acknowledged in both the diagnosis and treatment of mental health concerns. Therefore, treatment provided to marginalized groups like the queer community, disadvantaged castes, religious minorities in India, etc., needs to take into account their lived experience of injustice and trauma, lack of access to resources, and other disadvantages.
One of the largest battles in therapy is to locate the individual in the social context. Last year, I accompanied a counselor to a homeless shelter for individuals with AIDS and tuberculosis in Delhi. There, I observed the coping skills and support the counselor was able to offer to the group. However, it was heartbreaking to see that therapy or other mental health services would not be able to change the circumstances and the social oppression they were facing. The economic and social burden that contributes to mental suffering is often not something a counselor can change. I remember thinking this would be one of the hardest things to negotiate as a counselor. Thus, before locating the concern within the individual strategies for mental health, we should address the experiences of marginalized and disadvantaged populations. This is essential when the strategies are being adopted into new settings of low and middle-income countries.
Community Mental Health Care Programs
Let’s look at India – one of the biggest nations with a high proportion of the population living on a low income. 10 percent of India’s 1.3 billion people suffer from one or more mental health problems. According to WHO, 15 percent of the global mental, neurological, and substance abuse disorder burden lies in India. Furthermore, the number of mental health professionals in India is as low as 0.05 in Madhya Pradesh to 1.2 in Kerala for every 100,000 people. Thus, there is a dire need to develop frugal innovations that address the increasing treatment gap. In the context of citizens of the low-income population, frugal innovations aim to deliver affordable, adaptable, and accessible services. Integrating community mental health care programs into the infrastructure is a step towards this. Community mental health care programs aim to meet all well-being and mental health needs of the community. These programs often use the resources provided by the primary health care system and the community itself. The objectives include the promotion of well-being and mental health, psychosocial support, rehabilitation, prevention, treatment, and destigmatizing. In India, people often rely on faith healers for curing mental health concerns. Community programs can focus on using them as a resource to understand the local population and its needs better. Thus, it is crucial for the innovation in healthcare to look at how resources already available to a community can be used for providing care. Using local resources and health facilities adds multiple benefits to the mental health care system in low resource settings. It aids those suffering from mental health concerns by involving the community and helps bridge the treatment gap. For example, two mental health professionals in Spain felt disjointed with individualized therapy. To combat this they developed an intervention named ‘Interfamily therapy’ that facilitates groups with community members and families. Individuals in the group are either seeking therapy for mental health concerns or are caregivers/family members of those suffering. The interfamily therapy session helps build the capacity to listen, understand, and reflect on the other person’s suffering in the community. Involving the community for healing helps realize the social context, find social support, and ground growth into the everyday realities. It helps remove the stigma around mental health by making it a part of common conversations. And lastly, it helps erase the boundaries of discussing the person only in the constraints of the therapy room. A restorative circle is another example that keeps the community at the core of well-being. Using restorative justice circles in schools and the community has been successful in the rehabilitation of incarcerated students.
Henceforth, it is necessary to recognize intergenerational trauma and disadvantages faced by individuals in the therapy room. Adapting interventions developed in Western society need to be re-evaluated to acknowledge their effect on the marginalised and the local community. Integrating community care in mental health programs can help bridge the treatment gap in low resource settings. Therefore, to develop well-informed mental health care plans in low and middle-income countries, one must adopt a lens of intersectionality and support.