A recent study published in Medical Anthropology investigates the realities of community mental health initiatives like task-shifting in India. Using ethnographic insights from 2 mental health NGOs in Kerala, the study throws light on the benefits and unintended consequences of task-shifting.
Task-shifting is the process of training primary care and community health workers to take on the duties initially performed by specialists. The primary intention is to be able to reach a larger number of people with mental health issues, often referred to as addressing the ‘treatment gap’.
“Task-shifting is a medium through which the goal of universal coverage can be achieved in LMICs. For a massive population like India, task-shifting becomes essential. Our vision is to expand services geographically, and task-shifting is one way to achieve this.”
Community mental health initiatives in India are essentially valued and adopted for their potential to deal with a large and diverse set of population. Studies have shown the effectiveness of such programs to address the mental health issues of populated countries like India.
Task-shifting, like other initiatives, has its benefits and limits. In addition to solving the ‘treatment gap’, it creates new learning opportunities for volunteers and builds a community-based understanding of mental health. Contrarily, some shortcomings hamper these promising intentions. Often, such practices end up following the biomedical model of treatment, which they initially stood apart from. Consequently, the real issues like poverty, unemployment, and caste and gender-based discrimination are overlooked. Studies have shown that mindlessly using Western healing practices, making distress from reality a medical issue, and ignoring contextual/cultural research can weaken the impact of such initiatives.
While the growth of community mental health programs is well-documented through numerical data, there has been little investigation into the ground realities of such programs. Therefore, the present study is timely to conduct an ethnographic study of two mental health NGOs in Kerala. These NGOs, founded by psychiatrists, used existing palliative care infrastructure (buildings, vehicles, and the human capital of community volunteers) to reach patients. Fieldwork took place in clinics across five districts: Kozhikode, Malappuram, Wayanad, Ernakulam, and Alappuzha. The research involved attending clinics, interviewing 94 patients (with follow-ups for 53), 21 mental health professionals, 32 palliative care volunteers, and 59 caregivers, observing 143 clinical interventions, and analysing 47 case records. To gain deeper insights into patients’ surroundings/lives, 47 home visits also took place.
Kerala is uniquely positioned in the Indian mental health system. Despite comprising 3% of the Indian population, it houses ninety per cent of all palliative care programs in India. The ‘Kerala model’ of palliative care focuses on community involvement and home care. The volunteers come from all strata- shopkeepers, school children, and taxi drivers- with the shared intention of helping people in distress. On the surface, the collaboration of NGOs and PPC appears to bring together two opposing philosophies. However, the interviews reveal a more complex reality.
A senior palliative care physician in Kerala described the vision of palliative care as follows:
“The crux of palliative care constitutes community volunteers because they mobilise resources in their locality to provide interventions. Medicine was essentially care-based until the introduction of antibiotics, after which it became cure-based. In certain conditions, there is no cure; only care is possible. This very recognition of reality fuels palliative care. Some doctors would ask patients to take medicine post-dinner, but many don’t even have food to eat.”
In striking contrast, the chief psychiatrist of one of the NGOs described how the concept of psychosocial disability is taught while training community volunteers in mental health.
“Mental illness is just like any other non-communicable disease. It is a brain disease– that is how we look at it. We medicalise it to destigmatise it. We portray it [mental illness] as a neurological disease. It is a fact. Psychiatry is nothing but neurology. Even after awareness classes, many women complain that it is because of the fight with the mother-in-law that they got depression. However, this is not the case. It [depression] is an internal physiological problem which is wrongly attributed to external factors.”
This narrative of practices of NGO-run CMH in Kerala tells a different story. It was observed that integrating community volunteers into formal mental health systems compromises their freedom to work outside the biomedical framework, thereby taking away locally available and valued solutions to human distress. With the biomedical model dominating, volunteers tend to give medicinal treatments to structural issues like distress from domestic violence, sexual abuse, and inequality. When interventions are streamlined and scaled up in communities without engaging fully with local expertise and the specific sociohistorical contexts within which people with mental health conditions live and find support, they lose situational relevance, the ability to respond to changing needs within communities, and risk undermining local systems of care.
Several factors contribute to this.
- Volunteers’ willingness to appear as ‘scientific’ as mental health professionals shifts their priority to managing medication compliance over creating new care methods. Interventions to improve the socioeconomic positioning of the patients are also seen as attempts at medical compliance. A clinical psychologist explained:
“Poverty is the basic problem that patients present with. Most of them (85%) lack even food, proper shelter and clothes. The coastal area of Ponnani is really terrific that the patients are extremely poor. Women are not allowed to go to work for cultural reasons, forcing the family to live in penury. All suffer from stress. The majority of patients suffer from depression, anxiety, and schizophrenia, which are rooted in the lack of primary needs such as food. Many lack a secure home to live in. We started Mindfulness-based Stress Reduction (MBSR) therapy for them. Palliative volunteers even construct shelters and provide food for free, which increases treatment adherence. When such help is provided, patients will not resist taking [psychiatric] medicines.”
This reveals how psy disciplines often conceal real issues like poverty, unemployment, housing and literacy crises, and gender and caste inequalities by framing them as medical problems—a process known as the medicalisation of poverty.
Addressing social problems with medication in “pharmerging countries” like India contributes to “Psychopharmaceutical globalisation”. It also hints at the silencing of the voices of the patients. Some of the things that psychiatrists have done, not just for their patients but to their patients, is neglecting them as having any voice in the whole process.
- Volunteers who previously worked with terminally ill patients find more satisfaction in supporting those with psychosocial disabilities, as they feel more in control due to the possibility of medical intervention and tangible outcomes- people who complained of sleeplessness now sleep; those previously hearing voices now do not. One volunteer remarked:
“Psychiatry is not that difficult. In general home care [for physical illnesses] we have a lot of emotionally taxing work to be done: wound dressing, catheterisation, bathing, taking care of bedsores, to name a few. However, after all that, the person’s (health) is ultimately out of our hands.”
Medicalisation of Distress
In the NGO-PPC collaboration, medications are often used as the primary solution for all forms of suffering. This medicalisation occurs in three main ways:
- Awareness: “Change in Thoughts Is a Disease”
Despite mental health professionals acknowledging that dissonance in thought and behaviour is often rooted in social, economic, and political issues, training programs tend to emphasise medical treatment as the solution to these problems. As quoted from one of the interviews,
“Everybody has a pattern of thinking, which is normal. Change in thoughts is disease. Negative thoughts, having no happiness, no meaning in life, is seen in depression.”
This approach simplifies complex life concerns, reducing them to issues that can be addressed with medication, thereby avoiding deeper engagement with the real causes of distress.
Therapeutics: “Who Isn’t Taking Medicines?”
- Home visits by volunteers have become opportunities for moral policing, where checklists are used to ensure medical compliance, such as verifying medication intake while ignoring the broader socio-political context of the patient’s suffering. Fearing reprimand from the clinical team for non-compliance, volunteers often resort to persuasion or threats to ensure patients follow prescribed treatments. This reflects a hierarchical system that mirrors the caste-entrenched society in India. The fear of penalties drives a top-down approach, where volunteers feel pressured by psychiatrists, and patients, in turn, feel pressured by volunteers. To justify this, volunteers argue that while providing necessities like food and shelter is essential, medication remains the primary tool for addressing mental health issues.
Clinicians: The “Big” Doctors and the “Small” Doctors
- The clinical team in these NGOs includes a diverse range of professionals, such as psychiatric nurses, homoeopathic physicians, and recent graduates in social work and psychology. However, under the guise of task-shifting, these non-medical professionals often take on roles traditionally reserved for psychiatrists, such as prescribing medications. They are called “small doctors,” akin to junior doctors, while older doctors are called “big doctors.” If no new issues arise, they usually prescribe the same medications by writing “repeat.” If they need more guidance, they use ‘telepsychiatry’.
These observations raise questions about the effectiveness of task-shifting.
“Although task-shifting is stated to be an effective strategy, many of these studies measure effectiveness based on the range and scale of outreach rather than the quality of services delivered. In the context of a severe shortage of mental health specialists in India, rather than resulting in deprofessionalisation and demedicalization, task-shifting often results in professionalising and medicalising non-medical professionals, lay health workers, and community volunteers.”
Such studies raises the alarm for the state of Mental health care in India. If ignored, it can cause two main issues. One problem is that we start seeing psychiatric conditions as fixed and separate diseases, which is not entirely true. The other issue is that we might turn too many everyday things into medical problems, leading to the overuse of medications and treatments.
In a developing nation like India, free medicines (also tonics and injections) and easy access to ‘small doctors’ become highly attractive. When used judiciously by sensitive psychiatrists, these medicines can improve patients’ socioeconomic engagement, reduce symptoms and stigma. On the other hand, evidence also shows that these medicines often serve to suppress underlying issues like domestic violence, poverty, hunger, and social suffering. This leaves one to wonder who is ultimately responsible in such cases. Adverse impacts of medicines are blamed on the patients or written off as side effects, ignoring the social problems at hand.
Community-led palliative centres have the potential to offer alternative approaches to mainstream psychiatric care. Psychiatrists are moving towards approaches like deprescribing, and studies like this show that much is to be done to achieve this. The large social and economic differences are also reflected in their treatment. Research on how the homeless are cared for is a prime example. Such studies serve as a reminder that the quest for fair mental health treatment is challenging, and much remains to be achieved.
Researcher’s contact info: Dr. Sudarshan R Kottai
Department of Humanities and Social Sciences, Indian Institute of Technology Palakkad [email protected]
Article link: https://doi.org/10.1080/01459740.2020.1722122
