Some of our team members from the Rural Mental Health Programme (RMHP) – Sagyamary, Kavitha and Smriti – had gone on a three day exposure trip that took them all the way to picturesque Calicut in Kerala.
The aim was to visit an organisation, Mental Health Action Trust (MHAT), which is similar to The Banyan and also promotes mental health and offers free services to the poor and those in need. MHAT is run by Dr. Manoj, a senior psychiatrist.
The team visited various sites spread around three districts in Kerala- Malapuram, Kozhikode and Wayanad. They are very grateful to Dr Manoj and The Banyan for this exciting learning experience.
This exposure has proven to be quite beneficial to the RMHP team as they’ve returned with several new insights that will be of much use in improving The Banyan’s work in rural areas. Here’s a report, with more pictures, by Ms. Smriti Vallath.
“We arrived on the premises of MHAT early morning (5AM) on the 18th of December 2013 and met with Dr. Manoj, the founder and director of the organisation at 10AM the same day. We were given a brief orientation and the events and tasks for the following days were discussed and assigned.
BRIEF OVERVIEW: MHAT was founded in 2005 by Dr. Manoj and a fellow psychiatrist who currently runs a similar organisation called MEHAC in Cochin. Dr. Manoj now runs MHAT and has managed to liaise with 28 clinics in and around three districts in Kerala- Malapuram, Kozhikode (Calicut) and Waynad.
Decentralized model of community involvement: The MHAT follows a decentralised structure of functioning whereby they aim to only facilitate treatment and other services without drawing attention to the institution itself. The focus is still aimed at the clinics through which service is provided. The clinics are establishments in the community, most often focusing on palliative care. The doors of these are now open to the professionals from MHAT and service users in that area.
How do clinics get in touch? Most often, the clinics contact MHAT and seek help. MHAT then negotiates needs and an agreement is made.
What’s unique? The clinics have a volunteer system, much like our Community workers, only without pay. These volunteers are assigned clients whom they monitor on a regular-weekly basis. The clinics then call the volunteers for updates on patients and the psychiatrist on-call is notified if need be.
So how involved are the clinics, exactly? Total involvement! The clinics take onus for supply of medication, funding, service venue, rehabilitation, after care, and follow up. MHAT thus functions in the background whilst ensuring the show goes on- hopefully quite smoothly.
The Approach: MHAT believes in catering to the poorest population of Kerala. When a family with perceived need is isolated (usually by the volunteer) MHAT professionals complete a preliminary screening which includes assessment of socioeconomic status based on housing, family income, number of family members, level of education, possession of assets etc. After the evaluation, if it is felt that there is a genuine need in the household for access to free treatment, the service is extended. If not, referrals are made. In case there is significant doubt, further discussions with others in the team, the villagers and the volunteers are held. In some cases, the members of the households are also asked if they feel they really need free treatment and their opinion is taken into consideration.
“Sometimes, we find that household have all the luxury assets and yet appear to be distressed. In such doubtful situations, we ask the family. We explain to them the ethos of our organisation and that if they do think they can manage other paid services, they would be helping another family who needs this service to much larger extent”. – Sona, social worker.
General Functioning: In general, clinics are visited once a week. 20 minute appointments are scheduled for each client, however, others may be seen in case of emergency or if the client feels the need. Dr. Manoj aims to reduce medication and increase inter-review durations to a maximum of three months.
Additionally, it was quite interesting to note that not all clinics house psychiatrists on a regular basis. Considering the lack of human resources Dr Manoj alternates between clinics (although they have now two other psychiatrists working with them, who also visit the clinics). Clinics thus most usually always house only a social worker or psychologist, although the psychiatrist will be available via telephone, for emergencies.
“…In fact not all clinics require psychiatrists for regular evaluation. Others trained in clinical work can do the same job. In fact, others must be trained to do similar work. ” – Dr. Manoj. It ensures optimal flow of human resources.
DAY 1- PULAKIL, CALICUT
After a brief orientation, we were taken to visit Pulakil which is a community in Kozhikode with a palliative care clinic that liaises with MHAT. On a typical day, Out Patients are seen according to pre determined appointments. The professional on-call evaluates the client by reviewing their case and prescribing medication. Medications remain the same until a psychiatrists has permitted a change.
In Pulakil clinic the day care and rehabilitation program has received success and appreciation. The program involves 20 clients who during the day partake in different activities. The mid morning – afternoon session usually involves work such as tailoring, medicine cover making and so on. Post lunch clients engage in interpersonal activities such as antakshari, carom board, badminton, painting and general knowledge-question-answer round. The program is aimed at improving interpersonal communication, rapport, eye contact, verbalizations, and general mood.
“Clients have shown very good improvement. For example, X came in with severe disability in communication and thinking, but now she has resumed her studies and works well… where we have less success is with individuals with Mental Retardation, because there isn’t much that can be done after a certain point.” – Mr. Gafur, Day care supervisor.
- Fun Fact: During our visit there, we mingled with the clients and also sang along. Kavitha and Sagayamary sang ‘china china asai’- the aftermath of some very persistent people!
DAY 2 – 7: 15AM
Another early day! There were 8 clinics on the agenda and thus a plan to divide our visits was made. Sagayamary and the social worker Sona visited two clinics while Kavitha, Dr. Manoj, Jim (Psychologist) and myself visited clinics in Edakara, and Edavanna in Malapuram district of Kerala.
The morning clinic (Edakara) was quite hectic. We went on some home visits. During this time, one screening was observed- The professional, in this case a psychologist was attempting intake on quite a resistant client with paranoia, suspiciousness, decreased speech, poor/no eye contact, wandering tendencies, over protective of his daughter, poor ADL etc. The client was referred by a village volunteer. The client’s wife had suffered stroke and more recently had a complication and was in the hospital along with their only daughter. The client was being taken care of by his sister in law and her family who live in the neighboring house. After a couple of futile attempts, a decision to bring them to the clinic was made. The client however refused and remained resistant. They thus decided to take only his niece along.
In the clinic, the psychologist took a detailed case history and the doctor prescribed medication appropriately. It was explained that if the client refuses medication, a liquid of the same may be provided.
The second home visit involved reviewing a patient at their home. The client suffered from congenital blindness and progressive deafness. The client thus has significant mobility issues and is cared for by his daughter. The professional reviewed the case and called the doctor for a quick consultation. Medication was changed accordingly.
The third and final home visit included a girl with ovarian cancer seeking chemotherapy. The same procedure was followed.
We then returned to the clinic where a case review meeting, much like we have at The Banyan, was held. Follow ups were assigned for the week.
The same afternoon we visited another clinic. Patients were seen according to their appointments and a case review meeting was held in the end.
During this time, I was lucky to have spent a good amount of time with Dr. Manoj and definitely learned a lot from him. His aim to reduce medications and his approach to the same seemed quite impressive. The effort taken to get clients to the 3 month mark was also interesting, though quite arbitrary.
“As psychiatrists, we often over prescribe medications. Reducing them can offer better prognosis and functionality… Getting clients to the three month mark, reduces overcrowding of clinics and also encourages clients by giving them hope.” – Dr. Manoj- believes that though there is always a fear of relapse and resurfacing of symptoms, it’s a bridge that both the professional and client need to cross only when they reach it. Until then all care can be taken to sustain without/with less medication.
DAY 3- WAYNAD
The day began at 5 AM. We were picked up from a mutually convenient spot and drove through the beautiful ghat sections. The Clinic is situated at the peak of the Waynad hills amidst beautiful coffee plantations in a small town called ‘Ambalavazhi’. 300 psychiatric clients access the service at this clinic which also caters to patients with cancer. The same protocol as other clinics is followed here.
An interesting fact about this clinic was to note that most volunteers were females, as opposed to the larger male volunteers in other clinics.
- Fun Fact: The volunteers at this clinic made us feel so much at home, that Kavitha couldn’t help but get involved in their medical dispatch procedure. She assisted them in maintaining records and packing medications. She also taught them to make medicine covers out of old newspapers and encouraged them to get the clients involved in this process.
The clinic is one of the most poorly funded of all clinics and thus clients are given a maximum of two weeks medications only, though review appointments can be given up to a three month period.
Apart from Dr Manoj being brilliant at what he does, the entire project is well organized and systematic. There seemed to be little/no lag in reporting or arriving at clinics, even though they’re miles apart!
Dr. Manoj, until much recently was the only psychiatrist and shuttled from clinic to clinic. He thus has trained his staff on medication management and they’re now very much capable of altering medication dosage; although phone consultations are still made, especially for new medications.
MHAT’s role as facilitators allows them to take on only as much as they can/need to. They do not get involved with community complications unless they really need to. For example, any disputes in terms of appointments and screening are primarily solved by the clinic in-charge, though MHAT professionals may offer suggestions and background help.
The professionals are empathetic and ensure complete acceptance of client’s explanations for their illness.
“…Yeah we do have clients coming to us saying they didn’t take a particular medication the week because they want to wean off. During such circumstances, we do not get frustrated. We understand their reason and behavior and explain to them the importance of that medication and tell them that it may have made more sense to wean of medications like Lorazapam for example. Of course this is case specific; sometimes clients also prefer alternative medications compared to Western medication. We don’t force them, but ask them how else we may be able to help them and that they have access to these medications any time they may change their mind.”- Dr. Manoj
On simple observation, it was perceived that a larger population of the clients was given a diagnosis of BPAD.
“Unfortunately, psychiatrists assume models of illnesses that have seen during their training. As such if one sees more cases of psychosis, there is a tendency to lean towards a diagnosis that facilitates the same more than others. For example, in India, Schizophrenia has been over diagnosed. But in my opinion, if you look closely, they’re usually affective psychosis or chronic psychosis. I personally, thus train young psychologists and psychiatrists such that they do not give a diagnosis of schizophrenia after the 1st intake, but give one of acute/chronic psychosis. This can always be changed in later reviews once made sure.”- Dr. Manoj
- Fun Fact: Dr. Manoj skips lunch and most often breakfast as well. Sagayamary and I told him that our psychiatrist (Dr. Vimala Rao) has persistently told us that skipping meals can increase the risk of developing early onset dementia! After a few laughs, Dr Manoj, jokingly said “As psychologists your first instinct to that should have been to ask for references!” *Smiles*:-D
– Smriti Vallath
Contact Fanny for more info: +91-9884008643. firstname.lastname@example.org