Mental illness is not a personal
failure, it happens to most of us at one time or the other in life.
Mental, behavioural and social health problems are an increasing part
of health problems in the world. The WHO estimates that mental
and behavioural disorders constitute 12% of the global burden of
disease. Worldwide, nearly 450 million people have mental or
behavioural disorder (WHO 2001). The number of PWMI will increase
substantially in the coming decades for the following reasons. Firstly
the number of people living in the age groups of risk for certain
illness is increasing because of the changes in the demographic
features. Thus there has been increase in the number of person with
mental illness in the age group of 15- 45 years. Secondly, there has
been substantial increase in the geriatric population having mental
health problems, as the life expectancy is increasing. Thirdly,
there is an overall increase in the rate of depression seen in all age
groups as an effect of the changing socio- cultural-economic and
political situation of the modern world (Janardhan and Naidu, 2006;
Janardhan and Naidu 2007).
Mental illness in certain cases leads
to psychosocial disability (Tally and Murali 2001). Advances in
behavioural science have proven that mental and behavioural disorders
are treatable like any other physical illness (WHO 2001).
Unfortunately, in most countries mental health and disorders are low
priority, with no services in the community for treatment and
well-being. Though the burden resulting from psychiatric, psychosocial,
and behavioural disorders are enormous; it is grossly under represented
by conventional public health statistics. Nearly 10% of Disability
Adjusted Life Years (DALYs) across all age groups are due to depressive
disorders, suicides and alcohol related problems. It is estimated by
WHO that in 2020 the burden of mental disorders would increases to 15%
and mental disorders will be among the leading cause of global disease
burden by 2020, at which time, depression alone is expected to become
the second highest cause of death and disability world wide (WHO
If a person is unable to perform an activity
because of disease/illness or due to bodily impairment, the person is
considered as disabled. Though psychiatric disorders do not cause any
physical impairment, they can stop a person from doing many activities
that are expected of them. The disability in psychiatric illnesses is
dynamic being influenced by the nature of illness, phase of the
illness, treatment status and social support network available to them.
PWMI are treated as second-class citizens with no adequate facilities
or provision from the government. As a result, they face chronic ill
health and the families experience economic and social burden. In
certain cases this leads to social destitution.
Goal of Inclusion of people with mental illness in the CBR programme:
participate in societal activities, having access to generic services
as well as appropriate support and which they consent to.
Purpose of inclusion:
enable development practitioners to include mental health issues in the
existing CBR programmes through increased understanding of PWMI,
recognising psychosocial disabilities, appreciating the similarity in
approaches, cost effectiveness etc.
Basic Needs India (BNI), a
resource group in mental health and development believes that mental
health is a development issue; hence it can be included in the
development activities of the organizations. BNI provides technical
support to the CBOs and NGOs to include mental health issues in their
existing programmes. BNI has been successful in including PWMI in 50
CBOs and NGOs, carrying out CBR work and other development activities.
In the process, awareness has been created about the needs of PWMI in
the communities and among local and district level government
authorities. Many people recovering from mental illness and their
family members have joined self- help groups of people with
disabilities. While working with the CBR organizations in following
activities PWMI can be included.
CBR and people with mental illness
and changes in the concept of CBR over the last two decades has
influenced the thought of inclusion of mental health in CBR programmes.
The CBR strategy shifts rehabilitation interventions to homes and
communities of people with disabilities. Basic services are
provided or facilitated by CBR workers who are minimally qualified non
professionals but who are highly qualified change agents. The main goal
of rehabilitation has become broader and focuses beyond the individual,
to the family and communities in which people live. CBR
recognizes that breaking down barriers to inclusion in society is as
important to the mission of the CBR programme as is the functional
rehabilitation of individuals with disabilities. Thus the universal
mission of CBR is:
1. To enhance activities of daily life of disabled persons
To create awareness in disabled person’s environment to achieve barrier
free situations around him and help him in meeting all human rights.
To create a situation in which the community of the disabled persons,
participates fully and assimilate ownership of their integration in to
the society. The ownership lies with the affected persons. Maya Thomas and M.J Thomas 2003, Pritivish 2006).
above mission is no exception for PWMI. CBR programmes can link
with mental health professionals, users of mental health services, DPOs
and SHGs to broaden its scope to include people with psycho social
disabilities and to promote community mental health services
Indicators of readiness
In order to begin a mental health component in the CBR programme, the following readiness indicators should be demonstrated:
1. Organization’s willingness to work with mental illness
2. Basic understanding of the mental health concept/problem
3. A match of context between current CBR activities and mental health and development needs
4. Resource stability of the organization (Shoba Raja 2005)
Inclusion of mental health in to CBR:
There are a number of reasons why mental health should be integrated into community based rehabilitation programmes:
Community processes, full participation, equal opportunities, social
inclusion, gender, diversity and a focus on rights are some of the key
common elements of CBR work. Community mental health work is no
different so the programmes integrate well together.
The high prevalence of psychosocial disabilities emerging through
mental illness and its impact on communities, societies and economies
means that CBR workers are confronted with the issues in their
work. CBR programmes can have a positive impact on the lives of
PWMI, their families and on the situations in which people live by
including people with psychosocial disabilities in their programmes
there are a limited number of mental health professionals and mental
health services in low-income countries, making a CBR strategy
which empowers community level stakeholders to take action an important
the emerging trend away from vertical health programmes to integrated,
multipurpose health programme models favours primary level services and
community based strategies
there is an increasing recognition of the importance of early detection
and treatment of mental illness in order to prevent chronic conditions
the goal of continuity of care and inclusion of people who are mentally
ill into the community is more readily achieved when there is an
existing community based strategy
the prevalence of mental health problems among people with other
disabilities means that a mental health component in the CBR programmes
brings added value
The care for people with mental illness can be provided by :
Family members providing care to PWMI starts from baring all the
violent behaviour, to accompanying them for treatment, than
administering medicines, helping to engage in gainful productive work.
Community providing support for the well-being of PWMI. This is seen in
the form of not labelling them as mad people, giving opportunities and
advocating for the ensuring measures to meet the needs of PWMI.
Rehabilitation workers providing care for the PWMI and their families.
This starts with identification, assessment, follow up, home based
support and linking them to existing groups and mainstreaming.
Organization providing support to deal with other associated problems
of PWMI and their caregivers. This is seen in the form of conducting
camps, integrating them in to their existing programmes.
- Provided with the above support, the role of mental health professionals would be more meaningful.
Suggested Activities for inclusion of people with mental illness to be included in the existing CBR programmes:
1. Promote community based mental health services
community based services should emphasize on community acceptance,
family involvement, social integration and livelihood opportunities as
a key component of interventions while rehabilitating people with
disabilities. Similar approach is required for PWMI for integrating
them in to the community. An approach, where in medical inputs are seen
as a part of a larger whole including income generation and
mainstreaming individuals with mental health problems into the full
The community based organization, SACRED, included
mental health programme in their existing CBR programme. PWMI had
to travel 100 kilometres to attend the mental health camp conducted by
the National Institute of Mental Health And Neuro Science because there
were no services available in that district. With the support of the
federation of people with disabilities, PWMI were successful in
sensitising the district authorities and advocating for the
availability of mental health services with in the district. Of course
the struggle took more than three years for the appointment of
Psychiatrist in the District Hospital
Similar experience in
Koppal and Raichur districts, PWMI and their caregivers were travelling
10-12 hours to reach Karnataka Institute of Mental Health, Dharwad for
assessment, diagnosis and treatment services. Organizations of people
with disabilities promoted by CBR programme of Samuha sensitised the
authorities and were successful in getting the services with in their
district. Awareness building among family members and community
complemented the efforts.
2. Work with Disability people’s organizations (DPOs)
and service users to advocate for access to treatment: Access to treatment as near as possible
3. Involve people with mental illness and their families in livelihood programmes
A tale of market
S a beneficiary of the mental health programme implemented by
BasicNeeds India partner in Tamilnadu shares his experience. S
suffered from mental illness but has now recovered sufficiently to be
able to run a small enterprise selling cooking ingredients on his
bicycle. He rides about 35 kilometres per day on a regular set of
routes and has built up a network of established customers. At the
outset, he spent a good deal of time working out the various
ingredients that were likely to be in greatest demand, such as pepper
and coriander, and the quantities required. He sells small
packets tailored exactly to the needs of low-income customers who
purchase their requirements daily and at affordable prices. He earns 2
US dollars a day.
Before he became mentally ill, Mr V worked for
thirty years in the weaving industry. He gave it up and concentrated in
overcoming his illness with the support of his family. Following
treatment and ongoing assistance from an NGO, he decided to set up a
small business supplying snacks to travellers using the bus shelter in
his village. He starts preparing the food at 5.00am and sells from
8.00am until noon and than he rests. Trade has been consistently good
and he earns 3 US dollars a day. This income although modest, is
comparable to others in his village. He describes himself as having a
completely new beginning. He is confident and contented, enjoying the
relative freedom of the work that he does now. The local village
council was instrumental in his success, allowing Mr V to use the bus
shelter, which is a favourable location for his business
4. Promote community mental health services
health professionals in several low-income countries are actively
promoting Community Mental Health (CMH) and are attempting to influence
their governments to initiate measures to bring mental health into the
primary health care system. CBR programmes can work with mental health
professionals, local health centre staff and users of mental health
services to promote community mental health services. Many mental
health problems can be effectively resolved by working together with
people who experience mental illness in their own homes and
communities, using resources and support networks that are available to
them. Awareness raising campaigns and large-scale dissemination of
knowledge and skills would help in reducing the stigma attached to
illness. Building knowledge and awareness among families can make the
real difference, in ensuring that PWMI are integral members of the
family and community, participating in all social and cultural
Street theatres play
a major role in generating awareness in the community. Some
organizations also have formed puppet shows troops. Street plays can
provide knowledge on causes, treatments and symptoms of mental
illness. The purpose is to demystify the subject and to raise the
awareness of the public on mental health issues. Street theatres can
also highlight the important roles and responsibilities of families and
the community, which could go long way in rehabilitating PWMI. The
street theatre performances can be followed by question and answer
sessions, where people can ask specific questions.
Self help groups
groups are a common feature of CBR and development work. A self-help
group of women were clearly working hard to be strong in the face of
personal tragedy and unrelenting poverty. Comprising twelve members,
they came together with the support of CBR worker to promote savings of
Rs.100 per month per person so that individuals can accumulate enough
to buy a buffalo. This would then be a source of regular income, the
milk being sold to a cooperative at a guaranteed rate per litre. One of
the women had lost her husband to snakebite the previous week and so
the group was rallied around to support her and her three children.
link comes from the member living with schizophrenia, who has been
accepted as treasurer for her literacy skills (despite only having
stabilised her schizophrenia during the previous year). And she also
derives benefit as any other marginalized member of the group. Together
the group advocates for meeting the individual, group and community
This way they play an important role in integrating PWMI in main stream and provide mutual support to people in crisis.
5. Seek out alliances for training and mutual support
community organizations staff like community rehabilitation
workers/field staffs, coordinators of self-help/user groups and other
programmes, lay volunteers/ animators, nurses, and health workers; who
are not professionals in mental health or health care provide a variety
of services. Many of these informal community-care providers have
little or no formal mental health care training, but in many low income
countries they are the main source of community mental health
provision. They are usually accessible and generally well accepted in
local communities. They can help with the integration of people with
mental disorders into community activities and the other developmental
activities of their own organizations, and thus play an supportive role
in meeting the treatment needs of PWMI.
and their caregivers are encouraged to form an association of their
own. This provides a platform for them to discuss various
problems they share and find solutions. For example, Mr B’s, family
experienced unwelcome reactions of neighbours towards their son.
Mr B was wandering in the streets and his parents had to find him and
bring him back. The caregivers’ association in the village took the
responsibility to explain the illness to others. Mr B has now returned
to work as a labourer and is maintaining full-time employment.
caregivers association took the decision to advocate for their right to
treatment. The association members met the district authorities,
explained to them the need for treatment to be made available at their
block level. PWMI and their families decided to voice their needs
rather than depending on the local organizations. This resulted in the
deputation of a psychiatrist to conduct mental health camps in the
local health care centres on a monthly basis, with medicines being
distributed during these camps..
Some of the important roles of the CBR and the community development work force are:
- awareness creation and dissemination of information;
- identification of people with mental health problems and referral to health services;
- crisis support;
- home based support - supportive care, including basic information and counselling;
- helping in the activities of daily living skills and community reintegration;
- formation of caregivers groups/associations;
- advocating for the rights of PWMI;
- preventive and promotive services;
- Organising affected people to advocate for meeting their needs.
M, a young volunteer from a youth group in Jalahalli, took initiative
in supporting a woman who is mentally ill and destitute in his
village. He witnessed a shop keeper physically abusing (pushing) her
for entering his restaurant. Mr M took this abuse seriously. With the
help of an NGO he took her to the mental hospital for treatment,
following guidelines of mental health act for the involuntary
admission. After her discharge, he spoke with the woman’s relatives and
made arrangements for her stay and for her livelihood. People like Mr
M, volunteer to support NGOs in their work. NGOs also experience
stabilised people playing the role of volunteers and advocates. Always
people inspired by good work voluntarily offer assistance.
Advantages of inclusion of people with mental illness in the existing CBR programmes:
1. Meeting the needs of most disadvantaged group.
2. This promotes faster integration of PWMI into the mainstream societal activities.
3. Promotes good mental health in the community and leads to early identification.
4. Inclusion of PWMI in CBR programme would be cost effective.
5. CBR strategies and approaches very much fit in meeting the needs of PWMI.
Encourages innovative use of the resources that already exist (for
example street theatre troops, advocacy groups, etc.)
7. Inclusion would ensure coverage of all people with disabilities.
Mental health problems of people with disabilities are addressed, which
adds value to the existing CBR programme.
An environment would be built where in all disadvantaged groups
including PWMI fully participate in their own development and the
community in which they live in.
project head during one of the meeting expressed that because of
inclusion of the mental health programme, the credibility of the
organization has increased, the organization got more recognition in
the community and also in the district administration. The organization
leaders were invited to become members of the government constituted
boards. District authorities were appreciative and requests were
received to extend mental health services to other parts of the
Broaden understanding of the issues
practitioners need basic understanding of mental disorders. It is
essential to consult PWMI and their family members to listen to their
experiences, and needs aspirations to understand that particular
individual and the family. Training can be provided in basic
competencies, such as counselling- listening and communication skills
and need to maintain confidentiality, managing conflict of interests
while dealing with individuals as well as their families, maintaining a
neutral stance and dealing with disturbing emotions.
Outcomes expected from inclusion:
By including PWMI in CBR programmes, the following outcomes can be achieved:
• PWMI advocate for their rights and entitlements as equal and full participants in the disability movement
• PWMI participate in their own development and the development of communities in which they live
PWMI are listened to and are able to consent to or refuse treatment in
circumstances that are not life-threatening.
• PWMI have access to appropriate community-based treatment and support.
• Families of PWMI are provided with the support
• PWMI and their families are able to earn their livelihoods.
• Community health workers include mental health issues as an integral aspect of their work
• PWMI are able to access health care and educational services within and outside of the community
• PWMI participate in the social, cultural and religious life of their communities as they choose.
• PWMI fulfil their roles as community members, family members, parents and citizens
has been tested and proved that inclusion of mental health issues in
CBR programmes is possible, cost effective and help building an
environment where in people with all disabilities access their
entitlements and enjoy equal opportunities for full participation in
their own communities. A different and better world for all people,
including PWMI can be created through community based mental health
services, where in the communities understand issues related to mental
health, resulting in positive response to the issues. In this scenario
the families of people who are mentally ill are vitally involved
in bringing change in the attitude of the community. Through these an
environment of mutual understanding can be built, where in PWMI enjoy
Janardhan and Naidu(2006), Community Mental Health and
Development model evolved through consulting PWMI in Mental health by the
people Edited by Murthy 2006.
S Pruthvish (2006)
Community Based Rehabilitation of persons with Disabilities, Jaypee publishers
Shoba Raja, Director Policy
& Practice, BasicNeeds – CBR MH success indicators research study report -