Resilient Practices for Mental Health in Rural and Urban Uttarakhand
Background
In times of adversity or crisis, such as the current Covid-19 pandemic, global mental health has traditionally focused on documentation of increased mental distress, and service delivery for affected persons. However, it may be more pertinent to identify determinants of community mental health, and strengthen existing coping strategies., Mental health (MH) programs typically fail to build on available health assets, responding poorly to specific contexts and needs., , By describing the resources of communities, we acknowledge them as experts, active agents for their own health.
“Resilience” refers to individuals’ capacities to achieve wellbeing and thrive despite significant adversity. The concept merits consideration not only in crises such as the present one, but also given the hardship-filled daily lives of so many in India.
This article outlines key practices for self-care and MH as described by members of communities in Uttarakhand state, North India, who are disadvantaged by prevailing global and local social, economic and political structures.
The study
A qualitative study was carried out as part of a larger MH community assessment project of the Emmanuel Hospital Association that includes a study of factors central to recovery for people with psychosocial disability (PPSD).
Community health workers purposively selected participants who were seen as thriving despite adverse circumstances. The Burans team conducted in-depth interviews, collecting data from PPSD or caregivers in 8 informal urban settlements on the fringes of Dehradun city, and a mix of PPSD and other community members in 12 locations in the hilly rural district of Uttarkashi. We built on the concept of community asset mapping, defined as ‘documenting a community’s tangible and intangible resources, focusing on strengths as assets to preserve and enhance, not deficits to be remedied.’
Findings
We summarize here the key findings – seven practices for positive MH – with illustrative verbatim quotes.
Spending time in nature and with animals
To soothe distress, several participants sought natural surroundings, and animals. This required agency in contexts that limit freedom of movement for women. Some urban participants described sitting on their roofs or in the courtyard in the mornings and evenings, as well as engaging with animals; rural participants spent time in the fields, or going with others to cut grass or firewood:
‘We go with 8 or 10 women and take food with us and half the day we look out at the scenery and take rest and talk and half the time we cut grass. If we were feeling sad this makes us feel fresh again.’ (35-year-old woman, Uttarkashi district)
Social connections
Several spoke of conversation and company helping them feel lighter. One participant described her telephone conversations as almost prophylactic:
‘I also like talking to people on the phone. Early in the morning, the first thing I do is call my mother. The entire day goes well if I talk to her first thing in the morning. On days I do not talk, I feel very burdened.’ (44-year-old woman, PPSD, peri-urban Dehradun)
Choosing activity over despair
Work, or being active, appeared as a key strategy. Meaningful work, household tasks and income generation ranked high in helping reduce negativity and sadness. Adopting regular routines was integral to this practice. Participants described navigating between hope, hard work and despair:
‘I feel that hard work is all we have. We have to keep our spirits up, keep believing in our heart, and not commit suicide. I do think about suicide sometimes.’ (44-year-old woman, PPSD, peri-urban Dehradun)
Contributing to the community
Narratives emerged of sharing resources or information, or helping others, for instance when one PPSD takes another to hospital and shows them how to access care. This might work individually or collectively – as when groups come together to discuss issues:
‘This is one thing in the village that is good, if someone is sick then we all discuss and then others will come to support them and will cut their grass for them or take them to hospital. We also come together for a festival and each household contributes and we all feel good.’ (30-year-old man, health worker, Uttarkashi)
Practising religion
Some spoke of being spiritually engaged, describing their belief in God’s presence in difficult times, and practices such as daily visits to places of worship, as sources of solace:
‘I feel relaxed and my mind is at peace when I pray or seek God’s help. I worship for my longer life and wellness.’ (57-year-old woman, PPSD, Uttarkashi)
Choosing to practise self-care
Others talked about consciously pursuing activities that worked for their mental health and wellbeing: daily exercises with YouTube videos; lingering over their morning chai. A caregiver with many stressors said:
‘When I am feeling troubled, I take time to sit in the fields for a while, and then I can come home and start work.’ (40-year-old man, carer of person with disability, Uttarkashi)
Focus on positive thinking
Some spoke of choosing to turn away from negative thoughts, and actively seeking positives (“benefit-finding”) – gratitude for family members’ good health, for instance, amid their own recent loss of employment. There was critical reflection around this approach:
‘Negative thoughts will not make the problem go away.’ (60-year-old woman from low-income settlement, peri-urban Dehradun)
Discussion
Practices such as these seven, followed by community members in Uttarakhand, exemplifying established therapies widely used by MH practitioners, besides newly emerging ones such as seeking time out in nature, are almost undocumented in low and middle income settings.
The Covid-19 era and its inevitable long-tailed aftermath present a critical opportunity for global and South Asian MH programs to examine determinants of community resilience (as was done after the 2008 tsunami in Asia), and build on ethno-cultural practices already located in communities with a view to developing grounded interventions and strengthening existing coping strategies., This dialogic approach could increase partnerships, and vest agency in people who are typically excluded.,
“Existing assets in communities carry many implications for MH at individual, social, and environmental levels.”
Implications
Existing assets in communities carry many implications for MH at individual, social, and environmental levels. The Government of India must recognize that MH is predominantly determined by social, economic and environmental factors outside of the health sector, and build supportive environments for MH into all policies. Such an approach could improve equity as well as mental health outcomes. For instance, if street and park urban design maximized access for low-income communities to plants, animals, and natural environments, this could enhance mental health for many. Other urban structures could act as resilience resources too, providing opportunities for learning and social connection, such as the Dharavi Dairy set up in a Mumbai slum.
One way to develop personal skills in MH is through co-producing programs to build resources and resilience with community members such as traditional healers, ASHA workers – ensuring the participation of people with lived experience of psychosocial disability, and engaging community peer support for PPSD., All initiatives of this nature would, of course, require resources and implementation at every level, from rural panchayats to the various concerned Ministries.
Conclusion
Recognizing mental health assets, and adapting and broadcasting existing practices employed by individuals and groups, is essential to build the collective imagination of community MH practitioners, policy makers, researchers and funders, and ultimately to support the growth of mentally healthy communities.
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