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Talk by Dr. P. Judy Ramesh Jeyakumar:

National Mental Health Forum arranged by Director of Mental Health At Sri-lanka Foundation institute. 14 July 2009

NET WORKING TO STAKEHOLDERS IN MENTAL HEALTH CARE

The Hon. Secretary of health, Director of Mental Health, The Directorate of mental health, country chairman of WHO, Consultant psychiatrists, Diploma holders in psychiatry, Medical officers in mental health, Nurses, Social workers, representatives of INGO,s and my dear friends.

First of all I must thank our Director of Mental Health and the Ministry for arranging this National Forum at Sri Lanka foundation institute when we can discuss mental health needs of Sri Lanka. I am honoured to be asked to speak on networking with stakeholders in providing mental health care. I work with a mental health team in a community-based mental health team in Kalmunai. I hold a diploma in psychiatry having been trained in Angoda Colombo and awarded the diploma in psychiatry. Now the in charge of our mental health unit and the

When we talk of mental health may people just think of mental illness – sometimes of madness and insanity. But health is not the converse of illness and mental health is not just the absence of mental illness, however we may define it and its definition is a very controversial issue even today.

"There is more to good health than just a physically healthy body, A healthy person should also have a healthy mind, A person with a healthy mind should be able to think clearly, should be able to deal with various day-to-day problems faced in life should enjoy good relations with friends, colleagues at work and family and should feel spiritually fulfilled so that he or she can bring happiness to others in the community. All this contributes towards having good mental health.

Some months back, we met our Minister of Health, Hon.Nimal Sripala De Silva; he made a very important statement when he told me that if a person points to another person with the index finger saying he or she is mad, actually 4 fingers are turned towards the person doing the pointing and it is that person who is doing something bad or mad. The stigma attached to people given a diagnosis of having a mental illness is something we should be ashamed of. That does not mean that people do not have problems, sometimes resulting in a person being very depressed or anxious or showing disturbance of behaviour. Often when this is extreme, what is called ‘mental illness’ is diagnosed and given various names like schizophrenia, paranoia and so on. The name is not what matters – in fact these names have been developed in western countries and often do not really mean much in other cultural settings, although they are useful in many ways. We have to get away from these names and think of people with problems as needing help and understanding. Of course what the help consists of is important too, and various stakeholders are involved in bringing about mental health care.

The system of psychiatry has been developed mainly in western countries and has valuable ways of helping people through various physical treatments like a variety of medications and also through methods of counselling and behavioural treatments. The treatments are generally

called bio-medical because they are based on biological understandings of human life. As you know, in non-western cultures like that in Sri Lanka, religion, family life and spirituality are very important part of people’s lives and how they see themselves. We do not see ourselves as purely biological beings. So many problems, including mental health problems that may be called ‘illness’ in the psychiatric system, are dealt with by what may be called religious healing, tovil in singala or “kalippu” in tamil by systems of help such as yoga and self-care that are consistent with our cultures here. When our cricketers experienced trauma as a result of terrorism in “Lahore” Pakistan, I think what they benefitted most from was not medication or western type counselling but a system of relieving anxiety based on Eastern traditions. Also we have here in Sri Lanka a rich inheritance of indigenous systems of medicine such as Ayurveda and Unani systems that people often prefer to western allopathic medicine. In fact, the narrow – what is called bio-medical - approach in psychiatry is now being criticised even in places like Europe and even the term psychiatry is being replaced by the term ‘mental health’. Another thing that is happening all over the world is that institutional care for people with mental health problems is being replaced by community care.

The WHO has warned that depressive disorders are getting commoner all over the world, with a prevalence of 5-10% in primary care settings. In fact we are told that depressive symptoms may be as high as 30% in the general population with women being twice as likely to be affected as men. Depression is rank 4 th in the classification of the top ten diseases causes morbidity in the world now, and depression will rank in first by 2010. We know that depression is largely caused by psychological difficulties and social problems, especially disruption and dislocation of communities. So the many years of conflict that Sri Lanka has experienced and the effects of the “tsunami” are likely to be reflected in high rates of depression. Although medication may play a part in this it is much more likely that psychosocial support and help that is consistent with the cultures of Sri Lankan people will have to play a big part. Also suicide rates are high in Sri Lanka and here again the remedy is unlikely to be just psychiatric treatment but psychosocial care that is consistent with Sri Lanka cultures and that may be counselling that is culturally sensitive and delivered in local languages, religious healing and such like local traditional methods like astrology.

Sri Lanka has some of the best primary care services in Asia but mental health care has been neglected for many years. Today, the government is committed to achieving equally high standards in mental health care services. In 2005, the mental health directorate published a strategy for mental health and there have been some improvements since then. The overall aim is to reduce the institutional location of mental health care and widen community care. However, Sri Lanka has very few consultant psychiatrists and many of them live and work in cities. There are only a handful of clinical psychologists in the country. The training of nurses in psychiatry and mental health work started only a few years ago. Trained social workers are very few in number and most social work in the peripheral mental health units are carried out by people trained primarily as counsellors. There are very few trained occupational therapists and nearly all work in the main hospital at Angoda.

In the last few years the Ministry of Health and the directorate of mental health with the help of the College of psychiatrists has taken action to fill the gaps in mental health services in the peripheral regions of the country by appointing diploma holders and medical officer’s in mental health. In order to full the gaps in non-medical cadres, the department has trained and appointed Community Support Officers (CSOs) by supports of WHO but still there are far too few of this cadre to provide much help in peripheral units. At the moment the CSO,s system collapsed and the patients get relapsed admitted frequently to the unite, I give you a

humble request to the health ministry and the director mental health recrude the CSO,s as grassroots workers and allow them to work in mental health and in the community.

The only way in which government mental health services can provide services in most parts of the country is to network with non-governmental community organisations and obtain whatever help they can get from international bodies.

WHO (2001) has set down certain principles of mental health care:

Continuity of care A wide range of services Partnerships with patients and families Involvement of the local community Integration with primary health care

In planning for the future development of mental health care it is essential that we plan for increasing community-based mental health care and, working to involve communities as much as possible in deciding what sort of services are best and most likely to be consistent with the social and cultural conditions of people themselves. The challenge for us in Sri Lanka is to build services that are based on principles and practices that are consistent with indigenous traditions and cultures of the people of the country and call on methods of value from our own traditional sources as well as western scientific knowledge and practice.

So the stakeholders for mental health in Sri Lanka should be wide.

1. Mental heath practitioners or various disciplines – psychiatry, psychology, social work,

counselling and community work.

2. Religious organisations – churches, mosques and temples

3. Community organisations and / or representatives of communities

4. People who are / have been patients – usually called consumers or users of services

5. Carers of patients or ex-patients

6. Indigenous healers working in the community

7. Non-governmental agencies that are working in psychosocial care or welfare

8. International organizations, especially WHO

Community-based mental health care has to be consistent with what communities want and will turn to and use in times of trouble when they have mental health problems. The services must be close to the community and delivered in their own language and consistent with their traditions; and they must address not just medical needs – treating ‘illness’ but provide for spiritual needs, social problems and cultural needs.

We can’t anticipate that government services can do all that. So community based mental health care must network with a wide variety of agencies and people available in the society, non-governmental agencies, religious organisations, healing systems and indigenous healers and so on. Local mental health services have to work flexibly learning from experience and changing ways of working according to need and circumstances. Resources are difficult so we have to look to international bodies to help both in training and funding capital developments. But it is important that the services themselves are always accountable to and work closely with the local community satisfying their needs and being consistent with the cultural and social expectations. It is important that we do not just import models of care

from other places but develop services that suit our own social and cultural needs and can be sustained within the resources available to us. The services need to be home-grown.

I shall describe in brief the services we have tried to develop in Kalmunai during the past two? years.

Aftermath of “Tsunami” of 2004, several INGO’s started work in the North and East. The post tsunami rehabilitation and reconstructions were very speedy and most people recovered very fast from the psychological as well as social disturbance they experienced. The resilience of the communities is very striking. What we see today is that the Tsunami victims’ living conditions and general wellbeing are comparatively much better than those of the war affected people of the area.

Our mental health unit and the clinic hall was build by IMHO(International Medical Health Organization) based in USA - non political, non profit charitable organization and cost nearly 6million. The 12 bedded male and female cubicles were built and donated to us by EHAD- CARTITAS Sri-Lanka and some equipments (ECT meachine,laptop,power point etc) and capacity building to the staffs was provided by (CAMH) Toranto, Canada. However, there was a great deal with small contributions by our own society in Kalmunai. Several consultants from around the world came and worked with us to help tsunami-affected people. They are still in touch with us. So we learned a lot from foreign visitors and we continue to communicate with them by e-mail about clinical problems with patients. So these foreign stakeholders continue to help us. Unfortunately we do not have ADSL facilities and this would help us greatly to improve our on-going networking.

We have a very small staff but they include two social workers who visit clients in their own homes and also make contacts with schools and other local agencies. Through them and myself too, we have been able to establish a network of ex-patients called the Kalmunai Mental Health Forum and promoted a self-help welfare organisation called Vasantham (consumer welfare association). Our aim is to develop if possible and funding is available a micro-credit scheme to help Vasantham support ex-patients in getting employment. A major issue is the stigma that ex-patients suffer and consequent reluctance of local employers to give them work. Whenever a person is admitted to our unit, he or she comes with a ‘bystander’ i.e. a relative who participates in caring, working closely with the staff. This means that the patient can leave the unit as soon as he or she is better to visit shops etc. outside and also means that patients are discharged back to their own home very soon in the care of someone who is well acquainted with there care, the medication they may have to take etc.

While we have maintained out links with international agencies and people, during the past three years we have developed a good rapport with the local community in Kalmunai and got to know the various agencies that provide for the mental health needs of people living in the area. Thus we have been able to respond to what we saw as the needs and wishes of the community we serve in Kalmunai. For example, we are now able to liaise with a healing centre at a local church (which have mainly Muslim and Hindu clients) and with indigenous healers. Also we have established a working relationship with a local counselling agency (NGO) so that counsellors contact clients from among patients or their relatives in the unit. If we feel that someone may be better served by another agency we have the confidence to suggest this.

Conclusions

You all can see our activities in the PowerPoint background.

In Kalmunai we have worked hard and I am fortunate in having a dedicated team and a great deal of support through international connections. As a team we are trying to implement the national mental health policy set by the Health Ministry and Director Mental Health, which is mainly to minimize level of institutional care and shift the focus of mental health care to community care.

As I said at the start, I am one of 40 diplomats around the country selected by a competitive exam and trained by college of psychiatrists more than 1 year ago. After passing the final exams I am bonded with ministry for 4 years to work in the periphery .We express our heartfelt thanks to Hon. Minister’s initiative in establishing this cadre and consultants psychiatrists for their valuable contribution to our training. However, most of the diplomats are worried about their future in terms of career development. We believe this is important if we are continue to provide good services to the people. What most of us do is community mental health. There is now a need to recognise this as a speciality and establish a Community-oriented mental health curriculum so that perhaps soon diplomats who work in community mental health can be recognised by postgraduate PGIM as community psychiatrists. I hope that the Director mental health and the college of psychiatrists would consider our request.

Thank you very much to you all listen my speech without any interruptions,

GOOD LUCK.

Dr.P.Judy Ramesh Jeyakumar