A Community-Based Approach to Mental Healthcare in Pakistan

Some of us are affected more than others, but the pandemic has definitively proved that we’re all in this together. Why then do we continue to rely almost entirely on individual-focused strategies to mental well-being instead of more inclusive collective models?

This is not to challenge the significance of personalized psychiatric care or other individual-focused mental health therapies. This is what takes place at the institutional level, but the ‘institution’ is saturated with rising cases - particularly during the pandemic - and even when it isn’t, it remains inaccessible to lower-income households. Mental, neurological, and substance abuse (MNS) conditions account for about 14% of the world’s healthcare burden, but remains inaccessible to up to three-quarters of the population in developing countries. The current approach, although effective for those who can afford and access it, simply does not cater to the masses.

Most developed countries are not unfamiliar with support groups for grief, trauma, substance abuse, depression, anxiety, and other mental health conditions. These are particularly useful because they allow a mental health counselor to engage a dozen or so affectees at a time, and more importantly, for the affectees to engage one another for support. However, such efforts are rare or even non-existent in most parts of Pakistan.

I find this awkward, because Pakistanis - pardon me for speaking broadly - have a strong, community-oriented culture. If I don’t call my distant aunt every month or so, I’d expect her to righteously complain to me over the phone, “Aap to hamari khabar hi nahin lete!” (“Why aren’t you checking up to see how I’m doing!”). Such interactions are by no means anomalous in Pakistan, as our culture proudly encourages social connectivity.

Mental Health Stigma and the Normal / Crazy Binary

“Normal” vs “Abnormal”

Where cultural stigma of MNS conditions exists, people see the population as being neatly divided into those who are “normal” and those are not. This is unhelpful for multiple reasons, because ‘good mental health’ is not merely the absence of psychiatric illness, but good productivity and quality of life. And quite often, people who satisfy the clinical criteria for psychiatric illness are disinclined to seek help for fear of stigma. Furthermore, institutional care usually comes into play after a mental health crisis has already occurred, like attempted suicide or a poorly-managed panic attack. It is generally more treatment-focused, than prevention-focused.

The introduction of a third layer of structured community support can be enormously helpful. This is not to say that community support does not already exist in Pakistan; simply that it not integrated with the healthcare system and therefore not always reliable. Friends and relatives may try and intervene to ease ease our emotional pain, but may not always know how; and at times, may unintentionally aggravate it.

A typical support group meeting at iO - The Space.

What does a structured peer support program look like?

A support group meeting involves about 6-12 people sitting together in a room, talking about their struggles in the presence of a trained mental counselor. A structure peer support program has the following advantages:

- There’s less stigma associated with these groups, as these are social gatherings without a set clinical agenda.
- It allows a mental health counselor to reach out to a large number of people at once.
- It allows a mental health counselor to screen the participants for signs of serious illness, and refer them for specialized care if needed.
- It usually empowers the participants and helps them overcome feelings of isolation; allowing them to exchange practical, experience-based information on managing their MNS conditions.

Multiple studies have found peer support groups to be quite beneficial in managing MNS conditions. At least one meta-analytical study has found peer support interventions to be as useful for treating depression as conventional CBT.

Integrating peer support programs into the wider healthcare system and social order

The World Health Organization has published training manuals as part of its Mental Health Gap Action Programme. They provide valuable detail in training healthcare providers and supervisors to run the intervention program.

In Pakistan, several clinics have taken the initiative of operating their own support programs. Soch Psychological Clinics in Islamabad, for example, collaborates frequently with community spaces like Cafe Sol and iO - The Space, and has its MH specialists voluntarily moderating support groups in the area.

The basic structure is that MH specialists, like psychiatrists and clinical psychologists, help train support counselors who are able to conduct support groups and identify more serious mental health conditions. These counselors do not provide therapy. They coordinate support meetings, create a safe environment for the community members to support each other, and if needed, refer people with greater healthcare needs to the specialists.

An excellent way of integrating mental healthcare delivery into an existing community health model, could be through Pakistan’s Lady Health Worker Program. Pakistan has over 100,000 LHWs going door-to-door across the country, providing primary healthcare and counseling to households. By training LHWs to identify MNS conditions, we can markedly improve mental healthcare delivery. This would also be useful for people who lack access to online support groups, or exhibit reluctance in sharing their problems to strangers in a support group.

The drawbacks of integrating mental healthcare services into the LHW program, involve the limitations of the LHW program itself. LHWs have often historically suffered from budgetary mismanagement by Pakistani government, with many protesting often about non-payment of wages which are already meager (about $50 a month). There are also security threats to LHWs that would need to be addressed.

Lastly, we can reach out to religious leaders to offer mental health guidance to their community members. Most Pakistanis are religious, and engaging religious leaders to expand community-based mental healthcare provision could be exceptionally useful. Spirituality, in general, is associated closely mental health and is a source of psychological comfort to many. The problem with this approach, however, would be fueling the myth that MNS conditions are ‘spiritual’ rather than medical problems. This approach will leave out non-religious or non-practicing Pakistanis, and could open a pathway to unethical proselytization to mentally vulnerable people.

Effects of the Pandemic

Community-based intervention appears more important than ever, as the world faces an emotional contagion along with a viral pandemic. Across the world, a sense of loss and injustice is easily palpable. We grieve, in our own different ways, the loss of freedom, intimacy, financial and social opportunities, and of course, the loss of human life.

MH specialists have, unsurprisingly, reported increased cases of anxiety and depression. Is it, however, the prevalence of ‘grief’ that is commonly overlooked. ‘Grief’, unlike depression and anxiety, is not a psychiatric condition under usual circumstances. They are managed somewhat differently, and a moderated support group can help differentiate between the two.

With physical distancing in effect, most support group activities have shifted online with mixed results. Although online support groups show promise, but in some studies, have shown reduced satisfaction and compliance among participants compared to face-to-face meetings.

Regardless, any community support - online or face-to-face - is preferable to no support. For now, iO is operating a number of support groups. If you like, you may register for the support group here.