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View of Mental Health First Aid and Indian Family System: A Comparative Overview

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Mental Health First Aid and Indian Family System: A Comparative Overview

1Mr. Prakash Makasare, 2Prof.Sr.Tessy Sebastian

1Faculty, College of Nursing, Govt. Medical College, Nagpur, Maharashtra, India.

Mobile:9225526202 Email:[email protected]

2Director,Nursing, DMIMS, Sawangi, Dist.Wardha, Maharashtra, India.

ABSTRACT

Mental Health first aid is still in infantile stage in India. The main reason being stigma of mental illness preventing mentally ill to access mental health facilities. Further the mental health first aid is required in mental health crisis such as irreversible losses and other significant life events leading to severe mental shock and mental pain. In India, traditionally the people in the family, close relatives, family friends and neighbors are usually available at the time of significant life events. The foregoing article is an attempt to identify if there is any resemblance Indian family system to psychological first aid module now in vogue worldwide.

Key Words: Mental Health First Aid, Indian Family System INTRODUCTION

In some cities people are approaching for mental health services but that is for very advanced cases of mental illness. Awareness to reach out for mental health services is improving in last one decade. Although the district mental health program existed since 1983 and the federal efforts took 67 years after independence to have independent mental health policy for India in 2014 and further it took almost 30 years to revise its Mental Health Act in 2017. Yet the number of mental illness cases are not significantly large in India. There are no adequate mental health facilities even today and those available are concentrated in urban region. Even in this scenario and voluminous population of 1.35 billion; there are not many geriatric homes, beggars’ homes, day care centers for mentally ill, senior citizen homes, clubs, old age homes and similar facilities in India. The Non-Government agencies working for mental health are also in limited number in India. The main predictor for the need of these facilities is inadequacy of support from family and friends of the mentally ill. There are again many ramifications to this inadequacy of families which vary from country to country and location to location. However, in Asian countries and more so in India, the largest democracy in the world, the families are found to support the mentally ill adequately in times of crisis.

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CONCEPT OF MENTAL HEALTH FIRST AID

The concept of Psychological and Mental Health First Aid dates back to the aftermath of World War II. The idea was universally promoted recently.1 As per the World Federation for Mental Health, one in four persons globally require psychological help in the form of psychological first aid. At least one in four adults will experience mental health difficulties at one time or the other but many will receive little or no help when they present in an emergency.2

With the introduction and training of general people for Basic Life Support (BLS) and Cardiopulmonary Resuscitation (CPR) without equipment in the 1960’s many people have benefitted from the intervention of a passer-by, and lives have been saved. Mental health crises and distress are viewed differently because of ignorance, poor knowledge, stigma and discrimination, the style of rearing, and meaning attached to the significant life events and loss.

There can be no health without mental health. Literature in social studies reveals that one of the prime causes of mental health illness is untoward/negative life events and severe losses and inadequate social support. Just like in an accident the first aid is important in not only saving the life but restoring it to normalcy, similarly the Mental health first aid is important not only to prevent the mental illness but also to restore the person to normal social productive life.

Recognizing this need of the time, WHO observed 2016 theme ‘Dignity in Mental Health — Psychological & Mental Health First Aid for All’. The main aim was to enable people to provide mental health first aid to all. It was expected that people in general feel more confident in tackling the discrimination, isolation and stigma, that continues to afflict people with mental health conditions, their families and carers even if it is a situational mental morbidity.2

Mental health first aid (MHFA)is the help offered to a person developing a mental health problem, experiencing a worsening of an existing mental health problem or in a mental health crisis. The first aid is given until appropriate professional help is received or until the crisis resolves.3Mental health first aid began in Australia in 2001.4 Mental health first aid can be offered by someone who may not be a mental health professional, and by someone in the person’s social circle e.g. family, friend, neighbor, colleague or someone working as a community leader, e.g. teacher, Nurse.

Psychological and mental health first aid is a skill and an art that need to be developed and learnt.5

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Mental health first aid is a minimum requirement usually rendered early and on the spot of mental crisis. Although the concept is very promising, both health professionals and lay persons lack understanding of the concept as well as the key steps of psychological first aid.

Psychological first aid aims to minimize the mental health damage. It also aims to identify those vulnerable to more severe mental health problems and to recognize those in need of specialized mental health treatment and services.6

To approach the person with a problem is the first step to successful administration of mental health first aid. Most of the times this very step is missed. An immediate help at the hour of crisis, is vital. The next key step is to listen nonjudgmentally. Most of time, people fail to listen, and if they do, they tend to be judgmental. Giving support and information is the next rational step followed by encouraging appropriate professional help.6

Psychological and mental distress can happen anywhere — in our homes, in our schools, in the workplace, on the transport system, in the supermarket, in public spaces, in the military and in hospital. Psychological and Mental Health First Aid is a potentially life-saving skill.7

Any mentally healthy person may provide mental health first aid, even without formal training of Mental Health First Aid. However, the skills can be greatly enhanced by Mental Health First Aid training. Training is required to recognize the cluster of symptoms of different mental illnesses and mental health crises, to provide initial help, and to guide a person towards appropriate treatments and supportive facilities. Many fail to recognize the mental health problems, many find it difficult to respond to the person in mental health crisis, Naturally, effective mental health treatments are sought much later if at all they are sought.

Lack of knowledge may result in people avoiding or not responding to someone with a mental health problem, or avoiding professional help for themselves.8

People with mental health problems may at times not have insight that they need help, or may be unaware that effective help is available for them. Some situations in life can cloud a person’s thinking and rational decision-making processes.

In such situations, people in immediate vicinity can and usually facilitate appropriate support.

When a mental health problem first arises, professional help is not always required. Any member of public can offer immediate first aid and assist the person to get appropriate professional help and supports.8

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FAMILY SYSTEM IN INDIA

In India, family is the key resource in the care of patients with physical as well as mental illness. Families play the role of primary caregivers. Indian tradition of interdependence and concern for near and dear ones in adversities is innate in Indian families. This also bridges the paucity of trained mental health professionals required to cater to the large number of mentally ill. The clinicians also depend on the family. Adequate family support is the need and strength of the patient, clinician and the healthcare administrators.9

Family is defined in many ways. It is considered as the body of persons who live in one house or under one head, including parents, children, servants. It is a group consisting of parents and their children, whether living together or not; in wider sense, all those who are nearly connected by blood or affinity. It is habitat of those descended, or claiming descent from a common ancestor.9

From the point of view of psychiatry, family indicates a group of individuals who live together during important phases of their life time and are bound to each other by biological and /or social and psychological relationship.10

Globally family is universal, permanent, nucleus of all social relationships, has an emotional basis, has a formative influence over its members, teaches its members their social responsibility and the necessity for co-operation and follows a social regulation.11

CHARACTERISTICS OF TRADITIONAL INDIAN FAMILIES

India has tremendous cultural and ethnic diversity. In India the family is the most important social institution that has survived through the ages. Indian society emphasizes family integrity, family loyalty, and family unity. Collectivism is reflected in readiness to cooperate with family members and extended kin on decisions affecting most aspects of life, including career choice, mate selection, and marriage.11

Indian family system is considered strong, stable, close, resilient and enduring. In India, families adhere to a patriarchal ideology, have familial value orientations, and follow traditional gender roles. Traditionally, ideal and desired family in India is the joint family. A joint family includes kinsmen, with three to four living generations, including uncles, aunts, nieces, nephews, and grandparents living together in the same household. The lines of hierarchy and authority are clearly drawn. Ideals of conduct are aimed at creating and maintaining family harmony. Women are especially strongly socialized to accept a secondary

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backup to meet the needs of all family members. Psychologically, family members have an intense emotional interdependence with one another. Family members have strong interpersonal empathy, closeness, loyalty, and interdependency.11

FAMILY AND MENTAL ILLNESS

Literature had shown that caregiver’s material, social, and psychological situation dominates their decision of caregiving. Feelings of close and interconnected with family, gender-role conditioning, and life situation are mainly prompting women to assume caregiver’s role. India did not have any formal system for caring for the mentally ill until Britishers colonized.

‘Mental asylums’ established by Britishers were similar to those in the European countries, where the community felt safe to keep the unwanted, dangerous mentally ill in closed institutions away from family and society.12

India has a long tradition of involving families in the treatment of mentally ill relatives. In 1957, Dr. Vidya Sagar, the then superintendent of Amritsar Mental Hospital, involved the family members of the mentally ill in the management. He also allowed them to stay with their patients in open tents in the hospital campus. He showed that the patients recovered fast and were taken back home.12However, this did not reduce the burden of care for a chronic illness.

The reduced work output of the patient and the stigma attached to mental illness were the main reasons for the "unwanted patient".

BENEFITS OF INVOLVING FAMILY IN THE CARE OF MENTALLY ILL

 The traditional joint family system in India is a source of social and economic support.

 Families teach and ensure tolerance of deviant behavior.

 Families have capacity to absorb additional roles in times of crisis.

 Families allow for diffusion of burden in families caring for the mentally ill.

 Families are responsible for mediating the good course and outcome of major mental disorders.

 Families reduce the hospital stay or day care attendance of the mentally ill patients.

 Extended and joint families are able to compensate for a dysfunctional member in terms of fewer expectations.

 Families can enhance the social integration of mentally ill patients

 Family members can spare the trained mental health personnel for their routine duties.

 Family can function as the primary care provider for the mentally ill.

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 Locus of care for mentally ill remains family in developing countries with large populations.

 Studies have shown that 95% of the cost of treatment of schizophrenia is borne by the family, which uses about half of its income in the patient’s treatment.13

 In the ‘social brain’ construct, family environment is the most immediate psychosocial milieu. Hence family plays an immense role in the management of psychiatric patients.

 Families can fulfill the physical, spiritual and emotional needs of its members.

 Families can be sensitive to needs of the family members.

 Families can communicate effectively.

 Families can provide support, security and encouragement.

 Families can initiate and maintain growth, produce relationships and experiences within and without the family.

 Families can maintain and create constructive and responsible relationships.

 Families can foster growth with and through children.

 Families can accept help when appropriate and also be capable of self-help.

 Families can perform family roles flexibly.

 Families can have mutual respect for the individuality of family members.

 Families can use a crisis or seemingly injurious experience as a means of growth.

 Families can have concern for family unity, loyalty and inter-family cooperation.

 Families can identify community resources.

 Families can be taught interventions to promote medication compliance.

 Families can implement interventions to promote early identification of relapse and swift resolution of the crises.

 It is easy guiding families to reduce social and personal disability.

 It is also easy guiding families to reframe expectations and moderate the affect in the home environment.

 It becomes easy guiding families to improve vocational functioning of the patient.

 Families can facilitate emotional support to caregivers.

 Families can play pivotal role in development of self-help groups for mutual support and networking among families.14

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IMPACT OF NUCLEAR FAMILY STRUCTURE ON MENTAL ILLNESS

In past few decades there has been some diversions from the traditional ideal Indian family.

The actual living arrangements differ widely depending on region, social status, and economic circumstances. There is transition from joint family to nuclear family system. Naturally the mental illness in the family has great impact on the functioning of nuclear family. The impact of mental illness on the caregivers from nuclear families is –

 Burden of care in terms of household disruptions, economic burden, caregivers’ loss of work, social, and leisure roles, and time spent negotiating the mental health, medical, social welfare, and sometimes criminal justice systems. The adverse effects on the household routine include care of children, disruption of relations within and outside the family, restriction of leisure time activities of caregivers, the strains placed on their finances and employment, the difficulties in dealing with dysfunctional and problem behavior faced by caregivers, and the impact on the mental and physical wellbeing of the carers.14

 Caregiving experience with its ramifications such as the caregiver’s own perception of the impact of caring. Caregiving may have negative psychological impact on the caregiver resulting in feelings of loss, depression, anxiety, anger, sorrow, hatred, uncertainty, guilt, shame or embarrassment, all of which result in much distress and suffering.15

 Psychological/Psychiatric comorbidity with the prevalence of subjective psychological distress ranging from 29 to 60% across different studies which used the General Health Questionnaire or similar criteria.15

 Stigma associated with mental illness affects the families negatively in the form of blame, shame, and contamination. Blame is typically attributed to poor parenting skills. The family members experience shame for being blamed for the mental illness. This shame leads to avoidance of contact with neighbours and friends. Contamination means close association with the stigmatized person might lead to diminished self-worth. Other negative consequences of stigma include restricted access to all kinds of facilities including healthcare services and discrimination. Stigma affects the chances of marriage of the patient, or another member of the family.15

"Expressed emotion", describe the level of criticism, hostility, and emotional over involvement in a family. High expressed emotion is a significant and robust cause of relapse in mental illnesses. Criticalness is essential components of expressed emotion and is associated with the poorest patient outcomes.15,16

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PREPARING FAMILIES FOR MENTAL HEALTH FIRST AID

The families specifically joint family and those in rural areas are found have better support system. This can be exploited to train at least one family member in rendering psychological mental health first aid to the people in immediate contact. Mental health first aid in the familiar setting by the familiar person shall be more acceptable, affordable, accessible and appealing to those in crisis. In delayed grief, the person will find his close one more approachable than an unknown professional. Traditionally the elderly in the families were providing mental health first aid in times of crisis. Although they were not trained, they were accepted and their suggestions were also accepted.

Thus community mental health is the need of hour and family should be the focus of training for empowering community for mental health services.

CONCLUSION:

Community based mental healthcare is the need of the time in India with limited number of trained mental health professionals. To involve non-specialists and paraprofessionals in the care of mentally ill and handicapped has become mandatory. Mental health first aid is required to be given as early as possible to prevent major mental illness. Preparing families for delivery of mental health first aid and involving family in the care of mentally ill is the immediate solution to the scarcity of mental health professionals and poorly distributed and ill-equipped mental health services. The Mental health Policy of India also recommends care of the mentally ill in the familiar surroundings by the familiar personnel. Families and Joint families in particular used be a great social support and provided for reduction in stigma and family burden of caregiving. This system needs to be rejuvenated for the better clinical outcomes of mental illness.

REFERENCES:

1. Blain D, Hoch P, Ryan VG. (1945) A course in psychological first aid and prevention. A preliminary report. American Journal of Psychiatry. 101 (5), 629-634

2. http://www.who.int/mental_health/world-mental-health-day/paper_wfmh_2016.pdf

3. Kitchener BA, Jorm AF, Kelly CM. Mental Health First Aid International Manual.

Melbourne: Mental Health First Aid International, 2015:

https://mhfa.com.au/shop/international-mhfa-manual-2015

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4. Jorm AF, Kitchener BA. Noting a landmark achievement: Mental Health First Aid training reaches 1% of Australian adults. Australian and New Zealand Journal of Psychiatry, 2011, 45: 808-13.

5. https://www.ncbi.nlm.nih.gov/pubmed/12359045

6. Jorm AF, Minas H, Langlands RL, Kelly CM. First aid guidelines for psychosis in Asian countries: a Delphi consensus study. Int J Ment Health Syst. 2008;2:2. [PMC free article] [PubMed].

7. http://www.who.int/mental_health/world-mental-health-day/paper_wfmh_2016.pdf 8. https://wfmh.global/wp-content/uploads/2016-wmhd-report-english.pdf

9. Ajit Avasthi. Preserve and strengthen family to promote mental health. Indian J Psychiatry.

2010 Apr-Jun; 52(2): 113–126.doi: 10.4103/0019-5545.64582

10. Sethi BB. Family as a potent therapeutic force. Indian J Psychiatry 1989;31:22-30.

11. Bhushan V, Sachdev DR, The Family. In : Introduction to Sociology. 26th Edition.

Allahabad: Kitabmahal Publishers; 2006. p. 291-322.

12. Heitzman J, Worden RL. India: A Country Study. Washington: GPO for the Library of Congress; 1995.

13. Anon. Innovations in neuropsychiatric services. NIMHANS J 1983;1:1-14

14. Grover S, Avasthi A, Chakrabarti S, Bhansali A, Kulhara P. Cost of care of schizophrenia:

A study of Indian out-patient attenders. Acta Psychiatr Scand 2005;112:54-63

15. Murthy RS. Family interventions and empowerment as an approach to enhance mental health resources in developing countries. World Psychiatry 2003;2:35-7.

16. Butzlaff RL, Hooley JM. Expressed emotion and psychiatric relapse. Arch Gen Psychiatry 1998;55:547-52.

17. Heru AM. Family Psychiatry: From Research to Practice. Am J Psychiatry 2006;163:962-8

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