This paper describes a distinctive one-month certification programme in Mental Health Education, designed, conceptualised and executed at National Institute of Mental Health and Neuro Sciences (NIMHANS), a renowned multidisciplinary tertiary care hospital and training institute for mental health and neurosciences in India. A wide variety of topics integral to mental health education were covered in a short time frame by experts in the field of mental health through novel methodologies. This brief report details the first-hand experiences of the three participants and their perspectives on the content and format of the programme and its potential applications. Learning’s can have a profound impact on significantly enhancing the evidence-based support for developing strategies that enhance the Mental Health Literacy of the community.
Key words: Mental Health Education; Public Mental Health; Certificate course; NIMHANS, Mental Health, Mental Health Policy, India.
The 1 month Certificate Course in Mental Health Education conceptualized, materialized and executed by Department of Mental Health Education, NIMHANS, a premiere institute for Mental Health and Neurosciences in India aims to contribute to the pool of evidence towards enhancing the Mental Health Literacy of the community by honing the skills of the available human resources in the country that is plagued with shortage of trained mental health professionals to creatively address the needs of persons with mental illness.
Mental illness is a major public health issue. The National Mental Health Survey of India 2015-2016 conducted by NIMHANS (1) estimated the mental morbidity of individuals above the age of 18 years as 10.6% and the life time prevalence as 13.7%. There is a marked lack of awareness, diluted further with diverse culture, ethnicity, comorbid illness, stigma, limited human resources for mental health care and poorly integrated service delivery systems. All these contributing majorly to the existing rates of mental illness in a populous country like India, where an estimated 150 million people need mental health intervention at some point of their life time, including both acute and chronic care, in both the urban and rural populations.(1).
Mental health can be enhanced by effective public health interventions. Promoting awareness about prevalence of mental health disorders increases effectiveness of to seek help (2). Hence, it becomes imperative to develop an expertise in mental health education domain consisting of individuals in the community who otherwise are not professionally trained in the usual mental health disciplines, because they do not typically possess preconceived notions and hence probably less nonjudgmental, can be more effective in working with certain segments of the community at large.
Certificate Course Rationale
Tones and Tilford (2001) described health promotion is a product of health education and healthy public policy. The World Health Organization (3) defines health education as consciously constructed opportunities for learning which are designed to facilitate changes in behavior towards a pre-determined health goal. Mental Health education alongside other key public health interventions is frequently used to promote the mental health of individuals, families, communities and societies. Capability, defined by Stephenson (1998), as an integration of knowledge, skills, personal qualities and understanding used appropriately and effectively, is becoming an increasingly important concept in mental health practice (Sainsbury Centre for Mental Health, 2001). Being able to mold a health professional to progress to become a capable mental health educator requires a training platform exclusive to Mental Health Education. National Institute of Mental Health and Neurosciences (NIMHANS) is a premier medical institution in Bangalore, a city in South India. The Department of Mental Health Education, NIMHANS aims to promote the health and wellbeing of individuals and communities by developing health education and training materials that will help in meeting one of key goal of the National Mental Health Plan of enhancing the understating of mental health in the country(4). A one-month full-time certification program in Mental Health Education from Department of Mental Health Education, NIMHANS conducted in the month of September 2016 meant to get a step closer towards this objective. This is the first of the kind of course in India. The course was targeted to intake individuals with Master’s degree in health and behavioral sciences, selection based purely on merit basis. The three participants, who successfully completed the intensive program, were from diverse backgrounds having a post graduate degree in public health, psychology and rehabilitation counselling
Program: Conduct, application, and effectiveness.
The 1 month structured certification program in Mental Health education was a six day per week program. As highlighted in the course structure under table 1, a wide variety of topics integral to Mental Health and education were covered in a short time frame by experts from multidisciplinary domains including clinical psychology, behavioral sciences, psychiatry, epidemiology, public health, psychiatric rehabilitation, psychiatric social work, yogic science and team from a non-governmental organization working in the field of Mental Health. The course facilitators work with users and carers in mental health services and used their practical experiences to address the learning objectives of the different modules. The early sessions were tightly structured, thoughtfully divided between mini-lectures and group exercises encouraging strong student participation. In this backdrop, a homework task was set aside for each week the tasks allotted were both individual and group based Subsequent sessions starting the week that followed would begin with detailed discussion and feedback from these tasks. The sessions were interwoven throughout with practical illustrations and examples from the service users’ experiences. The one-month course pedagogy was aimed to increase the potential for a multidisciplinary collaborative learning. Collaborative learning is deﬁned by Gokhale (1995) as “an instruction method in which learners at various performance levels work together in small groups toward a common goal”; the active exchange of ideas within small groups increases interest and promotes critical thinking (Gokhale, 1995). The common thread to collaborative learning through interaction and association with others is connected by a commitment to a shared goal (Littleton, 1999; Lewis, 2000). The goal here was to address mental health needs of the population by developing innovative strategies for encouraging active community participation.
Applications of the Mental Health Education Course:
The main objective of the Mental Health Education Certificate Course being striving to improve the mental health of not just an individual, but an entire community through innovative techniques and inputs, the practical applications outlined below facilitated to a great extent fulfill the objective.
a) Addressing stigma and discrimination towards mental illness: Service users, the beneficiaries of mental health services at times opt out to seek service completely or partially by not fully participating in the process of recovery. One of the important reasons for disconnects being stigma; trying to avoid being labeled mentally ill. Hence to understand firsthand what one goes through during this difficult phase of illness, course participants read the autobiographies, blogs, published ﬁrst person accounts of people with mental health vulnerabilities and their caregivers, anchored in an Indian context. Following the intense reading, a brainstorming discussion with domain experts helped the participants garner a deeper understanding into the historical context in which these are set, a range of views and experiences, impact on life, attitudes to treatment. The key learning of the entire activity was to ingrain in the fabric of mental health promotion, collaborative working between mental health professionals and service users, and their signiﬁcant others, thereby challenging traditional ways of thinking and working by attempting to break down any real or perceived barriers. This provided the basis for good practices by valuing and learning from everyone’s (user, caregiver and professional) experience and perspectives. The key learning was the need to develop strategies for working collaboratively with important key stakeholders, the service users, and carers.
b) The inclusion of non-mental health professionals aiding in non-stigmatized, experiential dissemination of mental health education: Mental health should be recognized as everybody’s business. This can broaden the scope and reach of mental health interventions, decrease stigma and position mental health more positively. This approach legitimizes and welcomes the inclusion of the voices of persons with mental illness and their caregivers in providing feedback and planning of mental health services (5). To strengthen this learning objective, the course participants reviewed a book “Sepia leaves” (6), written by a caregiver to a mother diagnosed with schizophrenia. The book highlights the stigma attached to the illness, its direct and indirect impact on the family, friends, and society. The book intended to illuminate the challenges of living with and caring for a mentally ill family member and provides the opportunity to “see beyond the disorder to glimpse the lives of people touched by schizophrenia” (7) The participants also had the opportunity for experiential learning, through a face to face interaction session with Amandeep Sandhu, the author of the book. This session facilitated the asking of questions on various aspects related to the book with a deeper understanding of the author’s emotional journey, interactions with mental health practitioners, and the process of coping.
In another assignment, course participants read two chapters from “A Book of Light” (Pinto, 2016) (8); Some Questions for a Brother (written by Ina Puri) and Abhimanyu, our son (written by Madhusudan Srinivas). The first chapter highlighting the strong bond between a brother and sister peppered with recollection of old yet fresh memories rekindled a lot of emotions. This made the participants understand the role of self in today’s society which on the outside appears to be strongly connected socially yet disconnected in reality. The second chapter is an experience of the father living with a son with Autism. Both the chapters were very thoughtfully chosen to make the participants understand that mental illness does not just limit to the disorder per se but one needs to look far and beyond other consequences that have an impact on the lives affected of those suffering from mental illness. Participants also reflected on the power of self-expression through writing about difficult encounters with mental illness; both its cathartic and educative functions. Personal accounts can change perceptions about mental illness in society and such narratives have only emerged more recently in India. The immersive assignments involving the two books, also helped to rekindle, refresh and restart conversations on mental health by increasing the understanding of what family members and caregivers of persons with mental illness need from a mental health education point of view.
c) Filling the lacunae of lack of sufficient trained mental health service providers: The program also addressed the felt need of training the course participants to become the trainer of the trainer. The participants were provided the opportunity to put their learnings to practice, thereby making it progressive by being provided with a platform to facilitate training sessions at the department. One such activity was to facilitate a Mental Health First Aid training session with the support of the domain experts. It was a 3 hour intense training session, the objective being helping the laypeople in the community to spot the early signs of the day to day mental health issues. Facilitating the training equipped the course participants with the skills, knowledge and confidence to recognize and respond to mental health problems, and further work towards increasing the awareness in the community by equipping members of the community with basic mental health first aid skills. The participants also developed a 10-minute interactive role play video on Mental Health first Aid, thoughtfully titled ‘Prayatn, A step to mental health first aid’ for the public with the objective of enhancing skills of the lay public to perform mental health first aid during a crisis; Prayatn having its root to origin Sanskrit word ‘Prayatna’ meaning effort. Its significance increased in the backdrop of the World Mental Health Day 2016, celebrated on October 10th, the theme for the year 2016 being “Mental Health first aid for all”.
d) Demystifying media representation of mental illness: Media Presentations of mental illness can have a powerful role in educating and influencing the public. Participants were provided with snippets of video clippings from Indian media that portrayed mental illness in myriad forms. The participants were made to explore if these media representations were appropriate and sensitive. People with mental illness were often portrayed in the media in ways that reinforced negative stereotyping. These unjust portrayals can shape the public’s perception of those with mental illness as people to be feared and ignored. The course participants were asked to do a creative group presentation comparing both the stereotypical or negative and accurate or balanced ways in which mental illness has been represented in Indian media. This presentation was enriched by discussions about portrayal of mental illnesses in the Indian film industry (‘Bollywood’) vis-a vis in Hollywood cinema. Bhugra (2006) concluded that Indian cinema needs to be more enlightened in this aspect. This would be possible only when efforts are made to ensure limit the negative portrayals which add more fuel to the burning fire of inaccurate perceptions on mental illness.
Effectiveness: The entire program had a multifaceted training approach which provided participants with varied opportunities to contemplate individually and work in small groups alongside having brainstorming discussions. Being given the liberty to use one’s own ideas to develop teaching materials, share original views and discuss on various unique exercises made the course very effective. Participants had the golden opportunity learn from various stakeholders including mental health experts, service user and caregivers. The opportunity to develop a video from basics on Mental Health First Aid for those getting trained to be mental health first aiders was an invigorating experience. The lasting presence of the video Prayatn, A step to mental health first aid developed by the course participants available to the public online leaves footprints of the program. This experience significantly contributed to enhancing qualities of creativity, taking initiative which has in turn paved way to increased conﬁdence and skills required to implement the learnings of the intensive yet a fun filled training program. One key suggested area of modification is to provide participants with experience of field based activities which would give a practical flavor to the entire program. It is also worthwhile to consider increasing the duration of the course to three months, thereby providing the participants more depth to plunge into the core areas of Mental Health Education. The goals of the program were met to a large extent, with participants taking back a treasure of learnings to be implemented. Participants look forward to enhance the mental and social health of communities at large by educating and empowering the public on mental health and related aspects.
Implications for theory, policy, and/or practice:
The Mental health Policy (4), which is central to addressing mental health problems of India as they exist, takes a holistic approach by not reducing mental health interventions to sheer disease and disability prevention. It takes into account need for all stakeholders to work synergistically and achieve policy goals as it is a dynamic policy, all-encompassing and growing with regular review and feedback from people. The much awaited Mental Health Care bill (9), a progressive rights based one, aims to protect rights of persons with mental illness and promote their access to mental health care. This illustrates how mental health care is emerging as an area of priority concern in India. The bill also mentions about the measures to be taken to address the human resource requirements of mental health services in the country by planning, developing and implementing educational and training programmes in collaboration with institutions of higher education and training, to increase the human resources available to deliver mental health interventions and to improve the skills of the available human resources to better address the needs of persons with mental illness.
Mental health promotion significantly requires intersectoral collaboration, i.e. participation and investments by sectors outside mental health. Within the working framework of National Mental Health policy of India (4), the role of mental health education in addressing mental health issues of our country becomes pivotal. At various levels, mental health educators interact with other key other stakeholders and play a pivotal role in bridging the gap between various stakeholders. Given the challenges of an overburdened mental health care set up in developing countries with limited human resources, having a long term training program with a post-graduate fellowship in Mental Health Education would be beneficial.
- National Mental Health Survey 2015-16 | Nimhans. (2016, October 10). Retrieved February 01, 2017, from http://www.nimhans.ac.in/national-mental-health-survey-2015-16
- Promoting mental health: concepts, emerging evidence, practice (Rep.). (2005). Retrieved February 01, 2017, from World Health Organization website: http://www.who.int/mental_health/evidence/MH_Promotion_Book.pdf
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- New Delhi: Ministry of Health, Government of India; 2014. Ministry of Health (MOH). National Mental Health Policy of India: New Pathways, New Hope.
- Corrigan, P. (2004). How Stigma Interferes With Mental Health Care. American Psychologist, 59(7), 614-625. doi:10.1037/0003-066x.59.7.614
- Sandhu, A. (2007). Sepia leaves. New Delhi: Tara Press.
- Sarin A. Not to be loose shunted. Indian J Psychiatry 2009;51:71
- Pinto, J. (Ed.). (2016). A Book of Light: When a Loved One Has a Different Mind. Speaking Tiger.
- The Mental Healthcare Bill 2016, as passed by the Rajya Sabha on 8 August 2016. Available at prsindia.org/uploads/media/Mental%20Health/Mental%20health%20care%20as%20passed%20by%20RS.pdf.