Dignity & first aid in mental health

Dignity in mental health is a very important issue to be addressed. The medical fraternity has made vast progress over the last century and psychiatry is no exception. However, large sections of the world's population are still struggling to get even the basic mental healthcare. Even the sections, who manage to get care, are stigmatized and often receive treatment in a setup that may be perceived as stigmatizing. Thus, there is an urgent need to focus on making mental healthcare available to all, while at the same time ensuring the dignity of the suffering people.

Psychological and mental health first aid is a skill that the world desperately needs to make it a better place to live in1. Several factors including, but not restricted to, social and political changes, have a constant impact on psychological and mental health, which further highlights this need. A recent report2 suggested that even though there is an enormous burden, mental health conditions continue to be brushed under the carpet by stigma and prejudice, fear of losing job, societal respect and so on. Besides, the direct effects of psychological and mental health first aid on improving health, sensitization and training of the masses will also help reduce stigma and prejudice. For instance, training in basic life support and cardiopulmonary resuscitation has saved many lives over the decades3. A similar idea should also be envisaged for mental health.

At least, a fourth of all adults will experience mental health problems at some point in their lifetime, and considering the resources available, first aid will have to be developed in a big way.

What is psychological and mental health first aid?

Psychological first aid: Just as in physical illnesses, mental health also needs and benefits from first aid. It is a bare minimum necessity and, as in physical conditions, is usually delivered early on and ‘on site’. Although much has been said about psychological first aid, both health professionals and lay persons alike, lack a good understanding of the concept as well as the key steps of psychological first aid. Psychological first aid4 aims to limit the mental health damage occurring as a result of an environmental insult and also identify those vulnerable to more severe problems. It also identifies those in need of specialized treatment services.

It is important to understand that psychological first aid is not to be administered stand- alone. It is to be integrated into, and done along with, other physical health and rescue interventions. Checking for safety and providing practical help is an important aspect of psychological first aid. It is important to understand that this has to be done in a non-intrusive manner. The aggrieved persons must feel relieved and not burdened by our actions. Similarly, listening to the suffering person is helpful, but not forcing them to reveal things that they do not wish to reveal. Pressurizing them to talk may do more harm than good. Simple measures such as assessment of current concerns and needs, as well as providing assistance for basic needs such as food, water and important information, is of paramount importance. Preventing persons from encountering further harm, while also providing support that comforts them, is among the core principles of psychological first aid.

Mental health first aid: Mental health first aid is the aid offered to a person either developing or already having a mental health problem15. In the latter scenario, worsening of the existing condition may be an indication. The ideal scenario is wherein the members of the community are aware and can deliver mental health first aid. Elaborate research support exists for such a concept and intervention. The first step to successful administration of mental health first aid is to approach the person with a problem. One often falters at this very step and fails to approach at the very least! Once that has been done, a brief assessment of what the problem is, and an immediate assistance at the hour of crisis, is important. The key next step is to listen nonjudgementally. Very often, people fail to listen, and if they do, they tend to be judgemental. Giving support and information is the next logical step followed by encouraging appropriate professional help. Finally, encouraging other supports such as self-help groups can provide the much-needed long-term support system.

Engaging the layperson

Considering the large burden of mental health problems and the scarce availability of trained workforce, engaging the layperson is an obviously important option. However, it is important to do so in a cost-effective manner, which is evidence-based and likely to work. The central conceptual tenets of such an approach are to have ‘evidence of effectiveness globally’ and ‘evidence of cultural acceptability locally’. The following guidelines have been obtained from an evidence-based project in our country6. The first important point is to simplify the language of the message to be given. Technical terms must be replaced with words that are easily understandable. The complex psychiatric interventions must be unpacked into components that are easier to deliver and effective. This is particularly important to train lay counsellors and for them to effectively deliver these interventions. These interventions must be delivered in a user-friendly way and closest to the person in need. This could be at his/her home or nearby health centres. The large masses must be converted into strength rather than burden by utilizing this available resource to create lay counsellors. Finally, the scarce and precious mental health professionals must be reallocated in a more judicious manner to ensure their maximum utility and reach.

Emphasizing the role of the society

Many of the factors influencing mental health are societal and structural. Poverty, discrimination, inequality and violence are all social aspects that influence mental health. Similarly, the way people are brought up, educated and trained also has an important bearing on mental health. Coping with a situation and solving a problem at hand are partly determined by the upbringing and skills learnt during early years. School-based interventions along these lines have suggested that strengthening coping and problem-solving skills in schoolchildren have mental health benefits7. In addition, it promotes de-stigmatizing of psychological conditions and improves the dignity of the mentally ill.

Dignity and equality of the mentally ill

An important element of dignity for the mentally ill is equality. This principle of equality is justified and well argued from a number of standpoints. For instance, a well-known argument in human rights discussions internationally is to eliminate discrimination in vulnerable groups and take it up as a priority. Persons with mental illnesses are to be accorded equal rights as others. The discrimination based on mental illness needs to be eliminated in all its forms. Clinicians and policymakers must pay particular attention to this problem. Clinicians have a moral obligation to advocate non-discriminatory practices.

In this context, social responsibility may be conceptualized as having four levels: individual, community, national and international. At the lowest level (of an individual), typical measures include advocacy, clear identification of stigmatization and education, in an attempt to change attitudes and possibly behaviour. It has been seen that many a time, educational efforts change the attitude, but not behaviour. At the community level, ensuring social justice begins by persons and their immediate environment understanding what is missing and what needs to be done. At a national or regional level, strengthening and empowering institutions are the important ways of promoting social justice. Such institutions must cut across all sectors such as educational to service delivery, government to private and big to small. At the global level, bodies of the stature of the United Nations have the leading role to play.

Role of primary care

Considering the huge burden of mental health disorders and non-disorder psychological problems, strengthening mental health identification and intervention is of paramount importance. The first step towards this is the importance of making the primary healthcare physician open to the possibility of identifying, evaluating, treating and preventing mental health problems. The next logical step is to empower them with the basic knowledge of identifying and treating mental health problems. They must be encouraged to demonstrate behaviour that serves as a model for others. This includes a number of behaviours such as to give importance to, and acknowledge, the reality of mental health issues; showing keenness and interest in identifying and resolving them; talking to them in a non-stigmatizing manner and displaying a general demeanour of acceptance. ‘Interventions’ as simple as empathic listening can have substantial mental health benefits although may not appear as dramatic as a cardiopulmonary resuscitation.

In conclusion, there is an imminent need to sensitize and train the masses in psychological and mental health first aid measures considering the large burden of mental health problems and meagre resources available. At the same time, these interventions need to be administered in a non-judgemental and non-prejudicial manner with full dignity being meted out to the sufferer.