Community-based Mental Health Care Program

Component: Community-based Rehabilitation

Introduction: Mental health is a state of well-being in which a person realizes his/her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make contribution to his/her community. Mental health is inseparable part of general health, essential for the well-being and functioning of individuals, families, communities and societies. Mental health has a low priority on the development agenda and for society in general. There is lack of knowledge about mental health issues, with widespread stigma, prejudice and discrimination. In every community, there are people living with mental health problems who are likely to be isolated, abused and deprived of their fundamental human rights. In Khyber Pukhtunkhwa (KPK) Province of Pakistan, people with mental health problems have extremely limited access to support and health services and have also been excluded from community-based rehabilitation program. In short, there is no as such concept of community-based rehabilitation for the treatment of people with mental health problems. In Year 2009, Friends of the Mind initiated Community-based Mental Health Care Program (CMHCP) in Union Council Tehkal Payan of District Peshawar, KPK. The program was initiated after successful conclusion of rehabilitation of 10 Schizophrenic patients who were treated in a limited way within the community in Year 2008. CMHCP started its operation with a broader scope to address the goal of mental health well-being users end and community in general. The program operates multiple components at grass root level which includes function and operation of community mental health care center; awareness and mobilization; outpatient counseling and treatment; community-base rehabilitation with psychotic patients; psychosocial support and empowerment; and referral mechanism. CBR is the major component of the CMHCP and is functional since the inception of the program. More than 100 users are benefited from CBR component till now. Goal of CBR: Psychotic patients mostly schizophrenics and Bi-polar affective disorders are supported to develop and improve their insight and to enable them to participate proactively in community life The role of CBR: The main function of CBR component is to promote and protect the rights of mentally ill, support their recovery and facilitate their participation in their families and communities. It also contributes to the prevention of mental health problems and promotes mental health for all community members.

Desirable outcomes of CBR: Mental health is valued by all community members and recognized as a requirement for community development. Psychotic patients are included in CBR component. Communities have increased awareness about mental health, with a reduction in stigma and discrimination towards mentally ill mostly psychotics. Psychotic patients are able to access medical, psychological, social and economic interventions to support their recovery process. Family members receive emotional and practical support. Psychotic patients are empowered, with increased inclusion and participation in family and community life.

Criteria for selection of members for CBR: The following criteria are adopted for the selection of psychotic patients as members of CBR program: Easy accessibility of members to CBR team and FOMs center and vice versa; Willingness of member and family to participate in CBR process; Poorest and resource less; Member is suffering from psychosis (schizophrenia, Bi-polar affected disorder) and can be rehabilitated; Member is not suffering from other major or chronic disease. Mode of intervention under CBR component:
Mode of Intervention Activity Patient identified & received by FOM team on OPD basis 1st Phase Initial consultations (clinical diagnosis, medication, individual & family counseling and call for follow up) Motivation of family and patient for recovery & rehabilitation Informed consent from family Detailed assessment (need/vulnerability assessment under BIO-PSYCHO-SOCIAL paradigm) Treatment plan (clinical, psychological & social intervention)

2nd Phase

3rd Phase

4th Phase

Medical assistance (regular psychiatric check-up & medication) Psychological assistance (behavior modification, cognitive well being and emotional well being) Social assistance (domestic living, social living, livelihood recovery) Continued medication need based psychological and social assistance

Process of intervention under CBR component: 1ST PHASE: Identification & Referral: i. ii. iii. iv. v. vi. Identification and referral of psychotic patients are made through following way: Field visit made by center team (mostly by field officer & center facilitator) in target community; Through mental health awareness sessions inside community; Through free psychiatric/mental health camps inside community; By community activists from the target community; By already benefited patients and family within the community.

Initial Consultations: The patient is assessed for clinical diagnosis, medication and the family is assessed for its attitude towards the patient and his/her illness. Psychological assistance is provided to the patient through individual sessions and with family through family sessions. Psycho-education is provided to the patient and family regarding the patients current mental health condition and regarding the misconception related to mental disorder. The patient is called for follow up visits to check his response towards medication and other relevant assistance provided. The duration of 1st phase is for one month during which patient and family at least pay 2 to 3 visits. During this phase scope for future intervention with the patient & family is assessed. 2ND PHASE:

Patient and family member is further encouraged and motivated to take active participation in the recovery and rehabilitation process of the patient under CBR component. Informed consent is taken from family to ensure their active participation and support and to take responsibility of the patient on their own behalf in the whole recovery and rehabilitation process. Detailed assessment of the patient is conducted for identifying the need and for assessing the patients vulnerability under BIO-PSYCHO-SOCIAL paradigm. Treatment plan is developed on the basis of need identification for future intervention with the patient and family. The 2nd Phase is for limited time period and long for a maximum ten days. The patient is registered as member for CBR component. 3RD PHASE: 3rd Phase mainly consists of implementation of the treatment plan which was developed earlier for the recovery and rehabilitation of member. If member and family is supportive and cooperative the duration of 3rd phase goes for 4 to 6 months depends on case to case. During the third phase following assistance is provide to patient and family; Medical Assistance: Regular psychiatric consultation is ensured with the patient on weekly and/or bi weekly basis. During the psychiatric assistance which is provided by Psychiatrist/doctor proper medication and dose management is monitored. Compliance of the patient regarding medicines and monitoring of the adverse effect of medicines and keeping staff informed of changes in medication and the side effects and benefits are the part of psychiatric assistance. Psychological Assistance: Based on information obtained during detail assessment, objectives for psychological assistance is set accordingly. Psychologist/counselor mostly uses eclectic approach, i.e. different techniques from different therapies (supportive therapy, client-centered therapy, behavior therapy, family therapy), to address the members relational problems, behavioral problems, low self esteem, shyness, poor communication by involving both the member and his/her family in the form of individual, group and family sessions. The sessions are conducted on weekly and/or bi weekly basis. Social Assistance: During the entire intervention with member and family, social assistance which provided by field officer, center facilitator/counselor, psychologist and doctor is ensured in the following manner:

 Work with families to address the rights of members, ensuring their basic needs e.g. food, hygiene, clothing etc are met. Provide suggestions to family members about ways to include members in everyday family activities. Encourage members and their families to continue socializing with relatives and friends and to re-build relationships where necessary. Teaching different life skills like communication skills, overcoming shyness, raise self esteem, conflict resolution to members and family for improving social and domestic living. Encourage members to participate in income generating activities and sensitize family to support the member for improving their livelihood. Vocational guidance is provided to member and family on need basis. Motivation and sensitization with employers to give working opportunity to already skilled members. Engaging members and family in recreational, entertainment and social activities. 4th PHASE: As psychotic patients live with their illness for a lifelong, they need continuous support in shape of medical assistance and psycho-social assistance time to time. FOM facilitate all its members for a long period even if the patient is stable and back to work. Most of the benefited members are paying regular follow-up for more than years. Family of the benefited members also consulted the center on need basis. In such cases FOM only provide medical assistance in shape of psychiatric checkup and medicines and need based psychological and social assistance. Role of different staff members in the treatment: Team Leader/Manager: Team leader/manager act as program and administrative supervisor. His/her role is to ensure the smooth implementation of services by involving active and experienced team members. Psychiatrist: The psychiatrist shares responsibility for monitoring each patient/members clinical status and delivery of clinical services i.e.

psychiatric consultation (clinical/medical assessment and regular check-up) and medication. Psychologist: Psychologist play a role of mental health professional having responsibility for case management, teaching illness management and recovery skills, conducting counseling and psychotherapeutic sessions with members and family and monitoring the progress of member within the community; developing, directing, and providing other treatment and support services. Center Facilitator: Center facilitator plays both the role of psychiatric nurse and outreach counselor carry out functioning of initial medical assessment inside center and community; educate and assist members and families on medication and other health care provided to members in the community. Visit members and families at home for follow ups to assess and monitor the progress of members and for further need identification, motivate members and families for their smooth recovery. Field officer: Field officer has responsibility of identifying psychotic patients within community through field visits, facilitate awareness sessions with users end and community; work with families to address the social needs and issues of members; to seek opportunities for members and family for income generation activities; motivate and sensitize the community stakeholders like employers, community influential/activists and others for social uplift of users end. Common problems faced during the entire intervention: Members and family stop cooperating due to stability of member in the mid of treatment process which is considered by them as a full recovery and they think they required no further assistance which resulted in relapse because of discontinue medication and participation in recovery process. Most of the male members developed psychotic features due to hashish addiction i.e. THC (Tetra Hydro Cannabinol), which is an easy available drug in the target region. In some cases, members relapse due to re-addiction of hashish. Due limited budget for the project, it is difficult to provide direct financial grants or loans to end users, for example, when member is stable and needs financial support to participate in income generating activities like starting small business; if member is skilled and required tool kit for utilizing his/her skills for income generation etc. CBR component is operated under CMHCP framework; team/staff involved in CBR activities are also responsible for facilitating other project activities, which sometime affects the quality of CBR work. Staff to consumer ratio is also insufficient for the entire program and specifically for the CBR component.

Case Studies of Abdul Raziq, Fazal Karim & Gulroz: Fazal Karim: He was initially identified by his neighbors whose family member was already receiving services from FOM center. Center Facilitator (counselor) and field officer visited his home where they sensitized his family members about the illness and motivated him and his family to make initial visit to FOM center. The patient was brought by his brother to the center for assistance. He was having low self esteem and having problem of shyness due to which he isolated himself. Client-centered therapy and behavior therapy was applied due to which he became able to overcome his shyness and raised his self-esteem. He started participating in daily living activities. His brother encouraged him to work with him in his baking shop. Gulroz: His elder brother Zarshad was a registered member with FOM. Due to improvement in his mental health status and resuming his previous job after six years his sister in-law (Gulrozs wife) became motivated and brought her husband who was also having the same problems as Zarshad to FOM center for treatment. He had poor relationship with his wife due to jealousy delusion and with other family members due to persecutory delusion. His wife and family were not supportive with him due to lack of awareness regarding his mental illness. His wife was not admitting that he is suffering from severe mental disorder. Through family session with a goal of improving their relationship, psycho education regarding members current mental health status was given which resulted in positive change in attitude of family with the member. He was already skilled in wood furniture polishing and employed in wood furniture factory. He left his work after developing mental illness. When he became stable and motivated to work again, the field officer developed liaison with the owner of furniture factory. He sensitized him regarding the Gulrozs mental condition and educated him regarding the mental illness. The employer became sensitized. He agreed to hire Gulroz and to become empathic with him in form of concession in working hours and not to put heavy work burden. Abdul Raziq: Abdul Raziq was identified by FOMs community activist in his neighborhood. Community activist inform his wife and family about FOM center and its services. Abdul Raziq wifes visited the center alone for accessing detail information about the work and treatment. After receiving enough information she brought her husband to center for treatment. He was diagnosed as bi-polar affective disorder. Main focus was given to lower his aggressive behavior. Through different behavior modification tools and anger management techniques he learnt to manage his aggression which positively effect in his interpersonal relationship with his wife and family.

When he became stable, we worked with his family to support him in earning his livelihood. His brother became motivated and he assisted him in establishing and running a tuck shop. Conclusion: The whole process is conducted in decentralized way, where the already existing community center of FOM plays a role of hub from where all the CBR activities are planned and carried out inside the center and by visiting the members and family at their home and workplaces on need basis. The biggest difference between our mode of treatment with other conventional bodies is that we undertake vigorous follow-up within the community with focus attention at grass root level by providing mental health services right at the door steps of the users end/consumers.