MENTAL HEALTH

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Module details Name Affiliation Subject Name Social Work

Paper Name Mental Health

Module Mental Health and Advocacy

Paper Coordinator Dr. Asha Banu Soletti School of Social Work, TISS Module Writer

Dr.Vikram Gupta and Dr. Dr.Aarti Kelkar Khambete

Member, Mental Health Policy Group, Consultant to

organizations working on Mental Health

Keywords Advocacy, Stigma Rights and Challenges Summary

1. Definition of mental health as variously defined

2. Key concepts in mental health 3. Difference between Mental illness

and Mental health

4. Extent of the problem specially in India

5. Factors or conditions that affect mental health

6. Briefly discuss Stigma

7. Impact of mental health problems on the person, family and society 8. Rights of Person with mental

illness

9. Challenges of health care system in responding to the problem at hand

Content reviewer

Prof .Kalpana Sarathy Professor, Tata Institute of Social Sciences, Guwahati off-

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campus Language editor

Mr Venkatnarayanan Ganapathy Freelancer, Pune

Preface

Mental Health has long been neglected leading to unknown suffering for persons with mental health problems. Inadequate public and government attention has meant less information available for those who want to promote mental health and cope with mental health problems. Of late, significant initiatives have been taken by the government of India including introducing India’s first ever National Mental Health Policy and proposing Mental health care bill which has been passed by RajyaSabha and is awaiting consideration of LokSabha. More practitioners and users are coming together and discussing mental health. However, this effort is inadequate and more advocacy or championing of the cause is required. This module discusses rationale to take up mental health as a cause for advocacy and introduces the reader to advocacy. It also provides links to resources to help readers on their path to fight for mental health.

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Table of Content

Preface 28

MENTAL HEALTH 5

Learning Objectives: 5

What is mental health 5

Mental Health vs Mental Illness 5

Exhibit 1 6

Exhibit 2 7

Physical Health & Mental Health 8

Extent of the Problem 8

Mental health in India 9

Exhibit 3 10

Factors that lead to poor mental health 12

Stigma 12

Exhibit 5 13

Impact on Individual, Family and Society 13

Exhibit 6 Error! Bookmark not defined.

Rights of person with mental illness 16

Is the health care system equipped to deal with this? 17

Exhibit 7 17

Exhibit 8 18

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Exhibit 9 19

What is the prevalence of these illnesses? 19

Exhibit 10 20

ADVOCACY 21

Learning Objectives: 21

What is advocacy? 21

Exhibit 11 22

Need for advocacy in Mental Health 23

Exhibit 12 23

Exhibit 13 24

Exhibit 14 25

Effective advocacy: 26

Streams of advocacy 27

Exhibit 15 28

Exhibit 16 29

Multiple Choice Questions Error! Bookmark not defined.

Short Questions: Error! Bookmark not defined.

Section I

MENTAL HEALTH

Learning Objectives:

In this section, we discuss:

10. Definition of mental health as variously defined 11. Key concepts in mental health

12. Difference between Mental illness and Mental health 13. Extent of the problem specially in India

14. Factors or conditions that affect mental health 15. Briefly discuss Stigma

16. Impact of mental health problems on the person, family and society 17. Rights of Person with mental illness

18. Challenges of health care system in responding to the problem at hand

What is mental health

Mental health is defined as a state of well-being in which every individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community.¹

Mental Health vs Mental Illness

Mental health is not merely absence of mental illness. This statement is in line with position of WHO in its definition of Health. Current approaches to understanding mental health have moved

1http://www.who.int/features/factfiles/mental_health/en/ (accessed March 9, 2017)

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away from the narrow focus on prevention of mental illness or disorder and focus on promoting strengths and optimal functioning of individuals.

WHO stresses that a comprehensive definition of mental health should extend beyond the absence or presence of diagnosable psychological disorders to include “subjective well-being, perceived self-efﬁcacy, autonomy, competence, intergenerational dependence and recognition of the ability to realize one’s intellectual and emotional potential²”.

There are other points of view in defining mental health and illness. From the point of view of positive psychology or holism, mental health is described as an individual’s ability to enjoy life, obtain a balance between life activities and achieve psychological resilience. On the other hand, a mental disorder or mental illness is defined as an involuntary psychological or behavioral pattern that causes distress or disability which is not expected as part of normal development or culture³.

Exhibit 1

Psychological resilience is defined as an individual's ability to properly adapt to stress and adversity. Stress and adversity can come in the shape of family or relationship problems, health problems, or workplace and financial worries, among others⁴

The World Health Organisation (1981) defines mental health as “Mental health is the capacity of the individual, the group and the environment to interact with one another in ways that promote subjective well-being, the optimal development and use of mental abilities (cognitive, affective and relational), the achievement of individual and collective goals consistent with justice and the

2http://www.uniteforsight.org/mental-health/module1

3 Indian Journal of Psychiatry. 2017, 57 (Supple 2), 205-11. Women and mental health in India: An overview. Malhotra, S and Shah, R.

4https://en.wikipedia.org/wiki/Psychological_resilience

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attainment and preservation of conditions of fundamental equality”⁵.

A recurring theme in achieving resilience and well being is interaction of person with outside factors. The primary factor in resilience is having caring and supportive relationships within and outside the family. Relationships that create love and trust, provide role models and offer encouragement and reassurance help bolster a person's resilience⁶. Community mental health approach stresses on building such relationships amongst members in the community. It is with this view that community health care services are now promoted as an alternative to institution based services. Community mental health services involve community health providers who know the clients and their conditions well thereby helping develop resilience, promoting well being and adapt to mental illness or any other stressful condition. Such approaches are considered to be resource efficient.

Good mental health is related to mental and psychological well-being (WHO)⁷. WHO’s work to improve the mental health of individuals and society at large includes the promotion of mental well-being, the prevention of mental disorders, the protection of human rights and the care of people affected by mental disorders.

Exhibit 2

A person who displays positive psychological well being possesses qualities such as positive self acceptance, motivation for personal growth, positive relations with others, a purpose in life, a sense of comfort and control over the environment he or she lives in and the ability to take independent decisions⁸.

5 The International Journal of Indian Psychology. 2017, Volume 4, 2(92). Epidemiology of mental health and mental health issues of women in India: A literature review. Das, A.

6http://www.apa.org/helpcenter/road-resilience.aspx

7 http://www.who.int/topics/mental_health/en/

8https://www.psychologytoday.com/blog/theory-knowledge/201405/six-domains-psychological-well-being

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Physical Health & Mental Health

The use of term mental health implies that it is a distinct entity from physical health, the ailments of the body. The mind-body dualism is an artificial separation which is an artefact of the development of health sciences and does not reflect reality. Dr Brock Chisholm, the first Director General of WHO famously stated that “without mental health there can be no true physical health⁹”. Increasingly links are found between different physical and mental health states hence we should understand that the two aspects of health co-exist

Extent of the Problem

Mental health is one of the most important public health issues and is a major contributor (14%) to the global burden of diseases worldwide¹⁰. Major proportion of mental disorders come from low and middle income countries¹¹. The National Mental Health Policy distinguishes between mental health problems, mental illness and mental disability¹². Mental disorders can range from sub-clinical states to very severe forms of disorders. Mental health problems can manifest at the disorder/disease/syndrome level, which are considered to be relatively easy to recognise, diagnose and treat and include major and minor mental disorders. Major mental disorders are better recognisable while minor mental disorders are difficult to diagnose. Some mental health problems remain at the sub-clinical/non-clinical/sub-syndromal level and are difficult to recognize, define and diagnose and referred to as invisible mental health problems.¹³

The different mental &behavioural health problems have been defined and classified by the World Health Organisation in the Tenth Revision of the International Classification of Diseases

9 No physical health without mental health: lessons unlearned? KavithaKolappa,a David C Hendersona&

Sandeep P Kishore. http://www.who.int/bulletin/volumes/91/1/12-115063.pdf (accessed March 9, 2017)

10 Biomedical Research International, 2014, 979827, 1-7. Mental Health status among married working women residing in Bhubhaneshwar city, India: A psychosocial survey. Panigrahi, A., Padhy, P. and Panigrahi, M .

12 http://nrhm.gov.in/images/pdf/National_Health_Mental_Policy.pdf

13 Indian Journal of Psychiatry. 2010, 52(Supple 1), S95-S103. Indian Psychiatric epidemiological studies:

Learning from the past. Math, S B and Srinavasaraju, R.

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and Related Health Problems (ICD-10). This minimises ambiguity and allows for uniform nomenclature¹⁴. In order to make public health action easier, the World Health Organization (WHO) identified several priority mental health conditions that “represented a high burden (in terms of mortality, morbidity, and disability); caused large economic costs; or were associated with violations of human rights”. The priority conditions are depression, schizophrenia and other psychotic disorders, suicide, epilepsy, dementia, substance use disorders, and mental disorders in children.

Mental health in India

Epidemiological studies on mental and behavioral disorders done in India have found varying prevalence rates, ranging from 9.5 to 370 per 1000 population¹⁵. Among Indian population, the estimated prevalence of mental disorders is found to be 5.8%¹⁶A study conducted in Pune in 2012 found that the lifetime prevalence of mental disorders was 5 percent¹⁷. A study from Bangalore reports the prevalence of mental health disorders ranged from 9.5 to 102 per 1000 population¹⁸. Two studies on incidence show that it is over 16 per 1000 population and the trend is increasing¹⁹.

Studies such as those by Ganguly, (2000) on national prevalence rates for five mental disorders namely, schizophrenia, affective disorders (depression psychotic and neurotic), anxiety neurosis, hysteria (dissociative & conversion) and mental retardation found that prevalence rates for ‘all mental disorders’ were 70.5 (rural), 73 (urban) and 73 (rural + urban) per 1000 population²⁰. However in a recent all India National Mental Health survey conducted by by NIMHANS (2016) prevalence of mental disorders was found to be 2-3 times more in urban metros as compared to rural areas.

14 http://www.who.int/classifications/icd/en/GRNBOOK.pdf

15 Psychiatric epidemiology in India. Suresh Bada Math, C. R. Chandrashekar& Dinesh Bhugra. Indian J Med Res 126, September 2007, pp 183-192

16Int J Sci Res Publ. 2013;3:2250–3153.Mental Health Issues and Challenges in India: A Review.

Reddy VB, Gupta A, Lohiya A, KharyaP..

17 http://europepmc.org/articles/PMC4535113#ref6

18 Indian Journal of Psychiatry. 2010, 52(Supple 1), S95-S103. Indian Psychiatric epidemiological studies:

Learning from the past. Math, S B and Srinavasaraju, R.

20 Indian Journal of Psychiatry. 2000, 42(10), 14-20.Epidemiological findings on prevalence of mental disorders in India. Ganguli, H. C.

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The most widespread disorders were anxiety and depression. For schizophrenia, the national rate was 2.5 per 1000 and 10 out of 13 studies showed a rate of 4.3 or less. Mental retardation had a national value of 5.3 per 1000 and 80% of the scores were below 10.5/1000.

150 million Indians need mental health care services while only 30 million are accessing it²¹ Nearly 15% of Indian adults (those above 18 years) are in need of active interventions for one or more mental health issues. Common mental disorders, severe mental disorders and substance use problems coexist and the middle age working populations are affected most; while mental health problems among both adolescents and elderly are of serious concern.

Exhibit 3

Exhibit 4

21 National Mental Health Survey, 2015-16

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Rural -Urban percentage differences for national prevalence rates (Rural rate

= 100) Ganguly, 2000)

Mental disorders Rural/Urban ratio

Schizophrenia 100/69

Affective disorder depression (psychotic and neurotic) 100/90

Anxiety neurosis 100/106

Hysteria 100/44

Mental retardation 100/243

All mental disorders 100/103.5

The National Mental Health Policy distinguishes between mental health problems, mental illness and mental disability²². The different mental &behavioural health problems have been defined and classified by the World Health Organisation in the Tenth Revision of the International Classification of Diseases and Related Health Problems (ICD-10). This minimises ambiguity and allows for uniform nomenclature²³. In order to make public health action easier, the World Health Organization (WHO) identified several priority mental health conditions that “represented

22 http://nrhm.gov.in/images/pdf/National_Health_Mental_Policy.pdf

23 http://www.who.int/classifications/icd/en/GRNBOOK.pdf

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a high burden (in terms of mortality, morbidity, and disability); caused large economic costs; or were associated with violations of human rights”. The priority conditions are depression, schizophrenia and other psychotic disorders, suicide, epilepsy, dementia, substance use disorders, and mental disorders in children.

Factors that lead to poor mental health

Health and illnesses are influenced by a range of social, economic and environmental factors that can create unfavourable situations for individuals at different stages in their lives, making them vulnerable to mental disorders²⁴. Mental disorders affect everyone, irrespective of age, gender, residence and living standards, even though some groups are at a higher risk for certain illnesses;

only the impact varies. For example, mental disorders among children, depression among pregnant mothers, and dementia among the elderly are well known²⁵.

Social inequalities, poverty and discrimination often create these unfavourable circumstances leading to stressful situations leading to mental disorders²⁶.

Stigma

If there is enough and appropriate understanding on mental health including what conditions lead to good or poor mental health to some extent, then why do people suffer from mental health problems and if they do, then why don’t they take care from within their community and health care system or any other system available to them.

It is probably the stigma attached to mental health problems that is the single most important barrier to access any help by person with mental health problem. The knowledge of general public on mental health is poor and levels of stigma are very high. Further, there is a gender dimension to stigma²⁷

24 WHO (2014) Social determinants of mental health

25 National Mental Health Survey, 2015-16

26 WHO (2014) Social determinants of mental health

27 J Family Med Prim Care. 2015 Jul-Sep; 4(3): 449–453.doi: 10.4103/2249-4863.161352 PMCID:

PMC4535113. Perception of stigma toward mental illness in South India

Bhumika T. Venkatesh,1 Teddy Andrews,1Sreemathi S. Mayya,2Mannat M. Singh,1 and Shradha S.

Parsekar

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In 2001, the World Health Organization (WHO) identified stigma and discrimination towards mentally ill individuals as “the single most important barrier to overcome in the community”, and the WHO’s Mental Health Global Action Programme (mhGAP) cited advocacy against stigma and discrimination as one of its four core strategies for improving the state of global mental health²⁸

In addition to influencing whether mentally ill individuals experience social stigma, beliefs about mental illness can affect patients’ readiness and willingness to seek and adhere to treatment As a mental health advocate, one should prevent stigmatisation and discrimination against person with mental health problems in the community.

Exhibit 5

The Greeks who were apparently strong on visual aids, originated the term stigma to refer to bodily signs designed to expose something unusual and bad about the moral status of the signifier. The signs were cut or burnt into the body and advertised that the bearer was a slave, a criminal, a blemished person, ritually polluted, to be avoided, especially in public places…

(STIGMA, Notes on the management of Spoiled Identity by Erving Goffman)

Impact on Individual, Family and Society

Consequent to stigma, individuals with psychological disorders and their family members are at greater risk for decreased quality of life, educational difficulties, lowered productivity and poverty, social problems, vulnerability to abuse, and additional health problems²⁹.

Either a person with mental health problems could face individual discrimination or discrimination from structures like colleges, places of work, etc.

28 http://www.uniteforsight.org/mental-health/module7

29 http://www.uniteforsight.org/mental-health/module1

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It is now known that people with mental disorders have a mortality rate that is 2.22 times higher than the general population or people without mental disorders, with a decade of YPLL³⁰.

The exhibit below shows the impact of mental health problem on an individual, family / caregiver and on society as compared to a person without mental health problem.

30 Mortality in Mental Disorders and Global Disease Burden Implications A Systematic Review and Meta- analysis. JAMA Psychiatry. 2015 Apr; 72(4): 334–341.Elizabeth Reisinger Walker, PhD, MPH, MAT, Robin E. McGee, MPH, and Benjamin G. Druss, MD, MPH

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Exhibit 6

This exhibit attempts to present the differential experience of a person with mental health problem (shown in red) and a person without a mental health problem (shown in green) along different dimensions of impact. Lower scores are closer to inside of circle and higher scores represent a node near the rim of the circle. This is only for illustrative purpose

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Rights of person with mental illness

To reduce the extent of above impact, government of India has proposed a Mental health care³¹ bill which lists Rights of person with mental illness:

1. Right to access mental healthcare.

2. Right to community living.

3. Right to protection from cruel, inhuman and degrading treatment.

4. Right to equality and non-discrimination.

5. Right to information 6. Right to confidentiality

7. Restriction on release of information in respect of mental illness 8. Right to access medical records

9. Right to personal contacts and communication 10. Right to legal aid

11. Right to make complaints about deficiencies in provision of services.

Along with stating the rights, arrangements have been made to protect these rights. As an advocate of mental health, you could see if the rights of person with mental illness are upheld in the community you live in or not

Rights of person with mental health problems may be violated or they might not be aware of their own rights. In all these conditions, an advocate is required.

31 This bill has been passed by RajyaSabha (Bill No. LIV-C of 2013 AS PASSED BY THE RAJYA SABHA ON THE 8TH AUGUST, 2016)

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Is the health care system equipped to deal with this?

In order to increase the availability of mental health services, there are 5 key barriers that need to be overcome: the absence of mental health from the public health agenda and the implications for funding; the current organization of mental health services; lack of integration within primary care; inadequate human resources for mental health; and lack of public mental health leadership

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Action to support mental health at the community level provides a platform to develop and improve social norms, values and practices, while encouraging community empowerment and participation. Central to a number of community-based approaches is the realization that change within a community is best achieved through engaging people of the community. This change is brought about by efforts to improve key determinants of mental health, including a socially inclusive community, freedom from discrimination and violence, and access to economic resources. In many low- and middle-income countries, adequate human resources to deliver essential mental health care and interventions are lacking. However, a number of community- based interventions have been implemented to address this issue and compensate for the lack of health workers.

Exhibit 7

Burden of mental illness or psychosocial problems is grossly under reported by Public Health statistics which are obsessed with mortality statistics. Public Health focus on mental health was provided by the landmark World Health Report 2001 - “Mental Health: new hope, new understanding”

A suitable measure of the burden of mental illness is Disability Adjusted LIfe Year (DALY) which is a composite measure of both disability and premature death due to any cause, in this

32 http://www.who.int/features/factfiles/mental_health/mental_health_facts/en/index8.html

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case mental illness.

Statistics:

● The global burden of disease for neuropsychiatric disorders, as measured by the loss of DALYs, was estimated to be 6.8% worldwide in 1990.

● Psychiatric disorders account for 5 of 10 leading causes of disability as measured by years lived with a disability.

● The overall DALYs burden for neuropsychiatric disorders is projected to increase to 15% by the year 2020 and this increase is proportionately larger than for cardiovascular disease.³³

● Global Burden of Disease report, mental disorders accounts for 13% of total DALYs lost for Years Lived with Disability (YLD) with depression being the leading cause³⁴.

Exhibit 8

What conditions are covered in mental health problems?

Mental health problems include Mental, Behavioural& Substance Use Problems that lead to Disability, Morbidity and Death amongst sufferers

33 ICMR Bulletin, Vol. 31, No. 4

34 Global Burden of Disease Study 2013 Collaborators Global, regional, and national incidence, prevalence, and years lived with disability for 301 acute and chronic diseases and injuries in 188 countries, 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet. 2015 Aug 22;386(9995):743-800. doi: 10.1016/S01406736(15)60692-4. Epub 2015 Jun 7.

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Exhibit 9

Economic loss caused due to mental illness is significant, this opens up for advocacy for workplace policy for mental health

What is the prevalence of these illnesses?

A meta-analysis of psychiatric epidemiological studies in India has estimated prevalence rates per thousand population for various psychiatric disorders as follows:

● all psychoses (15.4),

● Epilepsy (4.4),

● mental retardation (6.9),

● alcohol/drug addiction (6.9),

● neurotic disorders (20.7).³⁵

As an advocate you must find data for your region although there is unlikely to be vast differences with data on severe illness worldwide. Lack of data of a region shows neglect of mental health in that region and you should collect data on mental health conditions like depression

35 Indian Journal of Psychiatry. 1998, 40: 149. Prevalence of mental and behavioural disorders in India : A meta-analysis. Reddy, M.V. and Chandrashekhar, C.R.

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Exhibit 10

Depression:

● Depression causes far higher morbidity in the community

● It is relatively common. It is stated that for about one-fifth to one-third of all patients attending primary health care clinics, depression is the principal or secondary reason for seeking care.

● Risk of Suicide is far higher amongst those with Depression

● Clear cut treatment guidelines are available that enable recovery from episodes of depression, but support over long time is required, yet people face barriers to care

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Section II

ADVOCACY

Learning Objectives:

In this section, we discuss:

1. Definition of advocacy

2. Need for advocacy in mental health 3. Key elements of effective advocacy 4. Different streams or types of advocacy

What is advocacy?

Advocacy is active promotion of a cause or principle that you strongly believe in. It involves actions that lead to a selected goal. Advocacy is one of many possible strategies, or ways to approach a problem and can be used as part of a community initiative, nested in with other components.

Advocacy does not necessarily involve confrontation or conflict³⁶

Advocacy usually involves getting government, business, schools, or some other large institution to correct an unfair or harmful situation affecting people in the community The situation may be resolved through persuasion, by compromise, or through political or legal action.

As an advocate you could provide different kind of advocacy services in mental health such as:

1. Community advocacy services

36 http://ctb.ku.edu/en/table-of-contents/advocacy/advocacy-principles/overview/main

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2. Advocacy for a specific cause

3. Group advocacy (also known as collective advocacy) 4. Peer advocacy

5. Statutory advocacy

The reader is advised to refer to this resource for further reading on types of advocacy - http://www.mind.org.uk/information-support/guides-to-support-and-services/advocacy/types-of- advocacy/#.WMF58oVOLIU

Exhibit 11

³⁷

37 WHO (2003) Advocacy for mental health

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Need for advocacy in Mental Health

Mental health has often been ignored and paid lip service to in defining priorities of health services and community action. Despite evidence to the contrary mental health has not been made the priority in line with other conditions like diabetes, cardiovascular diseases, etc. A brief example is the denial of person with mental illness coverage under health insurance offered by different insurance companies. Just as impact of mental illness is felt at different levels - person with mental health problem, family and society, similarly advocacy is required at all these levels to meet their unmet needs for information, participation in the care process.

In the community, planning of development programs specially basic services like drinking water, lighting of public spaces, transportation, employment, etc. should keep in mind the effect it would have on the mental health of the population. As more information is revealed on factors that influence mental health, policies are required to reflect the reality. Housing services and social security for society, protection against losses are all examples that require advocacy from mental health perspective.

Exhibit 12

The number of persons with major mental illnesses will increase substantially in the decades to come, for two reasons. First, the number of people living in the age groups of risk for certain illnesses are increasing because of changes in demographics. Thus the number of persons with schizophrenia will increase substantially because of increase in the population between 15 and 45 years of age the world over. Similarly there will be a substantial increase in the senile dementias, again by virtue of the increase in the number of people living to the age of 65 years and beyond. The second reason of overall increase in mental illnesses is that rates of

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depression have increased in recent decades, depression is now being seen at younger ages and with greater frequency world-wide (ICMR, 2001³⁸)

Resource allocation for specific action is a true reflection of intent. Historically, mental health services have received insignificant portion of health budgets and therefore National mental health program has not been yet upscaled to cover the entire country. The hospital based services are inadequate in their numbers as is the number of human resource required for service delivery.

Advocacy for enhanced resource allocation and optimum utilisation is important if status quo has to be changed. In community based approaches, effect of education services on young children, involvement in community activities, care of person with mental health problem need to be driven as agenda points to allow people to think what suits the community best from mental health perspective. Not all groups in community can articulate their needs for fear of reaction, hence advocacy is required to empower such groups and bring all perspectives to the table.

Exhibit 13

Gender determines vulnerability of men and women to illnesses. Differential power relations between men and women play an important role in influencing socioeconomic determinants of mental health, increasing their susceptibility to specific mental illnesses.

Common mental disorders such as depression, anxiety and somatic complaints are predominant among women, affecting as much as 1 in 3 people in the community. Unipolar depression, predicted to be the second leading cause of global disability burden by 2020, is twice as common in women as compared to men.

Alcohol dependence, on the other hand, is more than twice as high in men than women. Men

38 ICMR Bulletin, Vol. 31, No. 4, April 2001

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are also more than three times likely to be diagnosed with antisocial personality disorders than women.

Gender also influences the age and frequency of onset of symptoms, course, social adjustment and long term outcomes of these disorders.

There are no marked gender differences in the rates of severe mental disorders like schizophrenia and bipolar disorder that affect less than 2% of the population.

The disability associated with mental illness falls most heavily on those who experience three or more comorbid disorders. Again, women predominate (WHO³⁹)

Person with mental health problem and their caregivers need to be informed on their rights and roles so they can best utilise available resources for optimum recovery, this is only possible through advocacy for information services. Perhaps most important is the advocacy to reduce stigma and discrimination against person with mental health problem that acts as barriers in their accessing meaningful care.

Exhibit 14

Advance Directive

The Mental Health Care Bill, 2016 as passed by RajyaSabha proposes a mechanism called Advanced Directive. According to this provision that enhances rights of person with mental health problem towards self determination, every person, who is not a minor, shall have a right to make an advance directive in writing, the way the person wishes to be or not to be cared for and treated for a mental illness. Further, the person also has the right to appoint someone on

39 http://www.who.int/mental_health/prevention/genderwomen/en/

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his / her behalf to negotiate for his / her benefit. This is a revolutionary step which has come about through sustained advocacy by different interest groups. (Further reading, Mental Health Care Bill, 2016 as passed by RajyaSabha)

Effective advocacy

⁴⁰

:

● The rightness of the cause

● The power of the advocates (i.e., more of them is much better than less)

● The thoroughness with which the advocates researched the issues, the opposition, and the climate of opinion about the issue in the community

● Their skill in using the advocacy tools available (including the media)

● Above all, the selection of effective strategies and tactics

Advocacy is best to be taken up when routine efforts would not lead to change in the status quo which in no way is acceptable. The best time to start planning for an advocacy campaign is:

● When your direct experience or preliminary research shows you cannot achieve your goals in any other way

● When you are sure you have (or will have) the capacity to carry it through

● When you have enough enthusiasm and energy to last for what could be a long haul!

The basic components of advocacy include identification of your own strengths as an advocate if you are ready to face the worst case scenario if things go wrong. You should also have a good enough understanding of the issue at hand. You should validate most issues first hand and not rely on what others think or suggest. In community mental health since you would be talking to people you know very well, facts should be well checked and presented with respect to local culture and tradition to appear to be in best interest of the community.

40 http://ctb.ku.edu/en/table-of-contents/advocacy/advocacy-principles/overview/main

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In this journey, you should identify your friends and opponents who you are likely to face in this journey. Once you are reasonably clear of the situation, you should draw a plan for advocacy including budget.

The plan should be well articulated since many people in the community might like to read your position and the plan or associated documents are helpful in improving mental health literacy of the community including your opponents

Streams of advocacy

In India and other low income countries structured advocacy for mental health and person with mental health problems does not exist. This provides those who are looking to become mental health advocates ample opportunity since there is nothing much out there. what different kinds of advocate for mental health you could become:

a. Consumer advocate b. Policy advocate

c. Mental health budget advocate

d. Advocate to ensure compliance of country to international agreements like UNCRPD

e. Work place advocate for inclusion of person with psychosocial problems in work place or instituting prevention and promotion measures

f. Media advocate g. Legal advocate

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Exhibit 15

See the Person,

Not the Condition

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Exhibit 16

Images of some prominent advocacy initiatives (images have been taken from google only for illustrative purposes and not for any promotion of featured advocacy efforts

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