ROUND TABLES ON GOOD PRACTICES
IN MENTAL HEALTH: GUJARAT

Workshops design and facilitation
Bhargavi Davar, Ph. D.

Key Speakers and resource persons
Dr. Anil Shah (Senior Psychiatrist, Ahmedabad)
Dr. Ravindra Bakre (MHSP Co-ordinator, Gandhinagar)
Hon. Judge Jyotsna Yagnik
(Member Secretary, Gujarat Legal Services Authority, Ahmedabad)
Prof. Amita Dhanda (NALSAR, Hyderabad)
Dr. Ajay Chauhan (IMH, Ahmedabad)
Dr. Rakesh Shah (IMH, Baroda)
Dr. Sidhyartha Mukherjee (AKS, Ahmedabad)
Ms. Mobina (AWAG, Ahmedabad)

Documentation and report writing
Ms. Aparna Joshi (Bapu Trust)

Workshop Co-ordination
Ms. Chandra Kharadhkar (Bapu Trust)

Draft Report submitted to MHSP, Gujarat, by
Bapu Trust for Research on Mind and Discourse
February, 2006
Pune

BRIEF REPORT
Five Roundtables were held from August to November, 2005 on “Good Practices in the Mental Health Sector- Gujarat”. The themes of the Round Tables were as follows:

Round Table 1 – Values and Principles in the Mental Health Sector
Round Table 2- Good Practices in the context of Institutional Care
Round Table 3 – Good Practices in the context of Care and Treatment
Round Table 4 – Good Practices in the context of Community Care
Round Table 5 – Good Practices in the context of medico-legal opinion and certification

Bapu Trust was a core member of the Gujarat Mental Health Mission. The Mission Report highlighted the need to develop guidelines on Good Practices in the Mental Health sector, as a part of enabling the regulatory environment in Gujarat. These five Round Tables were organized as a follow up of this recommendation.

A play approach to ethics and ethical learning was adopted in the sessions. Play is here meant as creating virtual situations which will allow space for the imagination and spontaneity to work on possibilities rather than actualities / pragmatics. It was felt that this would be more enriching and may lighten heated controversies by externalising them.

The Mission Report was sure in its value of involving the different stake holder groups in such activities. With this in mind, participants were chosen. The local psychiatric association (Gujarat Psychiatric Society) and its key persons were invited. NGOs, women’s groups, disability groups, and self help groups working in Gujarat were invited. Clinical psychologists, social workers, psychiatric social workers and counselors were invited. The few carers’ groups working in the mental hospitals were invited. As in the Mission Report, however, it was difficult to involve the users, because user mobilization is nil in the sector, in Gujarat, as well as elsewhere in the country. For Bapu, this absence is significant, implying the need to intensify efforts to mobilize the users of psychiatric services.

The Mission Report had observed the conflict and negotiability of values between different stakeholder groups (users, carers, doctors, NGOs, policy makers). The Mission Report had also identified the core and subsidiary values inspiring the sector (e.g. autonomy, safety, honour, liberty, etc.) As the Round Tables were seen as also being inter-personal transactions of values, workshops were constructed in a structured and impersonal way, using case studies and role plays. Also, controversies exist in the sector where opinions are very divided, such as on ECT, involuntary treatment and forced treatment. Open ended discussions dove tailed these exercises. This approach was chosen in order to minimize the expression of conflict or aggression in the group. Also, the play and case study approach proved to be an educational exercise in articulating ethical issues, value dilemmas, and conflicts. The group was also enjoined to abide by agreed ground rules for constructive dialogue.

Ethics and ethical problem solving is not taught to mental health professionals any where in India. Values are taken to be personal and subjective, for which absolutely no training is required. However, as many of us will know as parents, or as teachers, we train our children and students into having some values and not having other values. Value education is a part of all learning. The case study method and role plays thus helped as training tools for making the group think about values, and problem solving in the ethical area. An advocacy platform was thus developed for talking about values, principles, ethics and good practices in the Gujarat Mental Health Sector.

The aim of the Round Tables was to have the groups’ consensus on various topics of ethics and ethical practice within the mental health sector. One of the members of the group shared the work being currently done by the Indian Psychiatric Society on clinical guidelines. The guidelines have more to do with clinical practices, mostly about medications. However, these Round Tables covered values, principles, basic services, quality of relationships between the client and the provider, referral systems, etc. and had a wider scope. The effort was not to develop clinical guidelines, but rather to clarify the do’s and don’ts at the service level. It is significant that in the Indian context, a platform was created on this topic, which was not a purely medical forum.

Inauguration
The consultations were inaugurated by Dr. Anil Shah. The first session in the series of Round Tables on Good Practices in mental health sector was held on 28th of August 2005 at AMA, Ahamadabad.

Dr Anil Shah, in his inaugural address first congratulated Bapu Trust for initiating an innovative workshop. He traced the history of mental health in India and Gujarat. The history of development of psychiatry both in Gujarat and India is about 50 year old. The pace of development was slow in the initial years, when psychiatry was not considered as an important branch in medicine. There were few training opportunities that existed. In 1957, he himself probably was one of the first students of psychiatry in Mumbai as the university had just floated the course. It was not given its due importance and was still considered as a pastime activity. As far as other fields in mental health were concerned, the situation was even worse. TISS was the only Institute, which offered a course in social work, and training opportunities for clinical psychologists were virtually nonexistent.

Through out the last 50 years, one has seen growth in training opportunities both in the medical as well as the non biomedical branches of mental health. There is also growth in research, especially in interesting areas such as community psychiatry, social psychiatry etc. During his training period as a psychiatrist, imipramine was the first and the only antidepressant introduced in the market. Now there is a tremendous growth in pharmacological research. Even psychology has grown as an independent field. A multidisciplinary approach has become a need of the day. The demand for non-biomedical services is also on rise. People are aware of the field of mental health.

Dr. Anil Shah, is a senior and eminent psychiatrist in Gujarat. He headed the Department of Psychiatry in B.J. medical College in Gujarat for more than 30 years. He is one of the first psychiatrists to have shown commitment to the field of mental health sector in Gujarat. He was also instrumental in adopting a true multidisciplinary approach in the institute’s Functioning. He has worked extensively to develop effective linkages between the government and Ngo sector in mental health. He is always known as an efficient professional.

The consultations on “Good practices in mental health”, happening in Gujarat, are very significant and are of relevance for every mental health practitioner. In earlier days, every doctor had to read a Hippocratic Oath. This was a fine document of ethics for every medical professional. Today, this practice does not exist, though it is still relevant.

Given the diversity of fields in the mental health sector, it becomes difficult to chalk out good practices, which are agreeable to everyone. The best persons to take feedback from in such a situation are the users and carers themselves. There is a need to develop a set of good practice guidelines, which are congruent with the user’s culture, background, needs, level of understanding and also with the discipline treating him/her. These guidelines can be flexible.

The issue of medico-legal responsibility has gained prominence in today’s world. Psychiatrists therefore have to be vigilant and alert. In reality, the number of medico -legal cases against a psychiatrist is least or near to zero, as compared to other medical practitioners in Gujarat. This does not mean that psychiatrists do not falter at all. We have to remember that psychiatry is one branch of medicine where defending oneself becomes difficult, due to the non-availability of biological evidence. Both the psychiatrist’s as well as the psychologist’s diagnosis and line of treatment can be challenged. The doctor has that much more responsibility in maintaining good practice.

The right to treatment and the right to refuse treatment is another important issue. Sometimes, you may, as a mental health professional, think that this person is in need of treatment, even though the person himself refuses to seek treatment. Therefore you decide to go ahead and treat that person. The person gets better with your treatment. However there is a possibility that he may not still acknowledge the importance of the treatment given by you. In the United States, and other European countries, a person has a right to refuse treatment. The patient can insist upon a particular kind of treatment. He cited a case from the United States, where a client refused to take ECT treatment and asked for cognitive behaviour therapy, as that was the next best option suggested to him. These therapeutic services were not available in the institute. So the patient sued the Director of the institute for having prolonged his stay in the institute. The Director finally had to pay him huge sums of money in compensation, both for prolonging his stay and for not making CBT services available in the institute.

In reality, it is the job of every mental health professional to suggest to the client, whatever is the best possible treatment option. This itself is an example of a good practice in mental health. Everything we do as a mental health professional should promote the user’s welfare and rehabilitation. It is also necessary to consider the user’s overall background before we plan any intervention.

Even though the participants present here belong to diverse fields, the same diversity could be put to use to develop good practice guidelines. Dr Shah noted that these workshops will definitely prove to be a milestone in the field of mental health.

The list of expectations from the participants was as follows:

Bhargavi Davar gave the preamble and background to the Round Tables.

The mental health sector in India has not created forums or dialogue platforms where ethical issues can be discussed. The Mission Report had emphasized the fact that the flow of information was top down: users and carers, particularly users, were left out of the dialogue process. The service exists in order to serve the needs of consumers, i.e. carers and users. Therefore, a consumer centered dialogue process was necessary. However, it is also to be acknowledged that there is little user led information (research or other data) in the Indian mental health sector.

The Mission Report had given the following as strategic directions for the next 2 to 3 years and as areas for interventions:

The Good Practices Round Tables are interventions aimed at detailing issues relating to patient interest and improving quality of care in the mental health sector. So far, the mental health sector has had few interventions of this sort and so the event is a significant one.

The goals set by the Mental Health Mission for mental health sector improvement were as follows:

These Round Tables are focused on increasing the quality of care and improving institutional mechanisms.

Among the strategic directions provided by the Gujarat Mission Report, those of relevance to this initiative are:

The Mission Report had also mentioned strengthening the ethics of care as a “cross cutting issue”. In spelling out what this means, the Mission Report had mentioned that ‘the ethics of care has to be cultivated across all service providers and settings’. The influence of values (1) service delivery, (2) care and treatment (ECT, medication, psychotherapy and counselling), (3) patient ethics, (4) gender ethics and (5) institutional ethics were explicitly mentioned.

External factors relevant to the Round Tables
There is a history of legal activism in India, including the PILs against various mental institutions in the North of India. Following the death of 28 people in a private shelter in Tamil Nadu, the Supreme Court has also taken suo moto action against all the state governments regarding the proper implementation of the Mental Health Act, 1987. In this petition, there has been a call by advocacy agencies to center the discussion within the context of users’ expectations and experiences.

We must also take note of the political negotiations involving all Governments of the world, the National Human Rights Commissions of all countries, and the International NGOs, participating to finalise the United Nations’ Convention on the Rights of Persons with Disabilities. This initiative is important because India may be a signatory to this Convention and the future of the Mental Health sector improvements, including legal reform, would then be determined by this convention. The present situation with the Mental Health Act, 1987, is dissatisfactory to all stake holders, including the policy makers, institutional authorities, the private doctors, the carers and the users of psychiatric services. We must also situate these round tables against the greater Human Rights consciousness pervading in the health sector, with ever greater possibilities of user / carer mobilization and litigation.

The Mission Report’s position in this context is significant. The report noted that law should be used sparsely, for not all solutions to the ethical issues can come from law. Self regulation and the self discipline of services is more beneficial in the long run than law driven regulation. Disgruntled consumers will turn to law in an environment of judicial activism. Opportunities for installing self correcting mechanisms within the mental health sector will be lost.

Aims:
The overall purpose of these Round Tables were:

Sector approach to ethics of care
The Mission Report noted that, for developing the best practices guidelines, the following should be taken into account:

Other recommendations by the Mission Report included -

The values of different stakeholders in the mental health sector can be an accelerating factor or an impeding factor, as noted in the Mission Report:

“The values underlying the MH sector have until now not been formulated, discussed and integrated in practices. Creating awareness of values among the MH personnel and policy makers is important. Proper instruments can make this factor influential to sector performance”.

Levels of advocacy
There are different levels of advocacy that organizations could be involved with, in order to strengthen the regulatory environment of the mental health sector:

1. The use of law (e.g. SC intervention, litigation, UN convention work)
2. Research as an advocacy tool (e.g. health systems research, research on effectiveness, quality of care)
3. Model building of service programs (e.g. service program aimed to demonstrate one or more good practices)
4. Training and education (legal / ethical / technical concerns of diverse sectors)
5. Consensus building and opinion building (consultations, task forces, dialogue forums, etc.)

For these consultations, the last strategy of advocacy was most prominently used, i.e. dialogue, negotiation, opinion and consensus building among different stake holders. It was also noteworthy that this report would be presented before the Government of Gujarat, as a contribution to the ongoing efforts to strengthen the Mental Health sector. It was very important that all stakeholder views were heard in this process, and that each group was represented.

Process of Developing Good Practices

Many methods of developing good practices have been adopted around the world. Some of these methods are:

In the existing world literature, processes of developing good practices involved technical engagement with vision, values, principles, research, strategies and action. Ethical problem solving and decision making were technical skills, guided by ethical principles. The process some times involves policy makers’ consultations (with or without) multi-stakeholder participation. Research and documentation of good practices could be another way of raising the ethical sensitivity of the mental health sector. A third way is program modeling, as an organizational value issue. In this, program developers articulate and analyse ethical questions.

Research forms the back bone of the process by which good practices is developed in the mental health sector. Research could include studying the effectiveness of various treatment modalities; evidence base on various clinically defined disorders; user centered research or client satisfaction research; and documentation of ethical dilemmas and good practices across sectors; and quality of life impact studies. A variety of methods may be found in the literature on good practices, including, focus groups, survey methods, qualitative methods). Secondary analysis or evidence base reviews are also another often used method. Ethical research and research on evidence base is sadly missing in India.

Good practice instruments have a form and structure.

Good practices are specific formulations about ‘do’s’ and ‘don’ts’ and may have a specific logical or propositional form. They would be specific to the program, pilot or to the clinical intervention. It would describe a specific action, or a clinicial behaviour. The proposition would contain an operational verb (e.g. “Always tell the client about his / her diagnosis”). Taking that action would lead to a measurable impact on the client – provider relationship. (e.g. “Telling the client about the diagnosis results in greater compliance”). This process of developing very specific program related instruments on good practices can result in understanding how one’s values, principles and actions influences outcomes in the service interaction.

Chalking out values, principles and good practices is not just a matter of philosophizing, or moral theory. But it is also a matter of clinical tool building and therefore, it is a technical skill. Knowing how values are processed in the service provider - client interaction will lead to specific good practice actions which will consequently lead to improvements in the quality of care.

Good practice actions are not so much about being right or wrong, or a subjective feeling of having done well, but about how certain clinical behaviours can lead to better clinical outcomes. This is an objective exercise, involving developing criteria and tools. Instrumentation is required in this area, so that we know which kind of clinical behavioural actions lead to what sort of clinical outcomes.

This exercise also has to be based on research data, especially in the area of user expectations, user led research, efficacy studies which are participatory and study of the effectiveness of certain practices. At the end of these Round Tables, we should evolve a checklist or some thumb rules that could guide good practice in the mental health sector.

The process of developing good practices involved the following steps:

India lacks research or evidence base in the field of mental health. So we can talk about guiding principles instead of theory / evidence base. Some examples were provided of the concepts used and also the process.

A value is defined as a “core organizing principle” of our life / work. E.g. “participation”. Evidence base could be relating to the research on good outcomes where the client has made an active choice in the treatment, and has had greater participation. E.g. the issue could be about the clinical outcome of user choice of cognitive behaviour therapy over drugs. The research shows that more clients participate if given the choice. A good practice strategy in this case would be “enhance user participation in treatment plan”. Out of these steps, we can draw a good practice action such as, “Ask the user what she prefers, drugs or psychotherapy.”

Value >>> Evidence >>> Strategy >>>Action

Good Practices - Justifications for engaging with this topic
The mental health systems in India have been functioning for years without good practice guidelines. This needs to be explained. Also, we will have engage with reasons and justifications why this exercise must be done. A list of justifications was prepared and the groups discussed these justifications, adding or deleting words or sentences, or adding new ideas or challenging the enlisted ones.

1. Having Good Practices guidelines will improve the quality of care in the mental health system. It will enhance the performance of the mental health system in fulfilling its objective of providing a range of services, including preventive, promotive, outreach and curative services.

2. Having Good Practices guidelines will help in the regulation of the mental health service delivery system, so that it serves the needs of mental health service [users] in a standardized manner.

3. Good Practices guidelines are needed in order to customise Mental Health services to meet the diverse and individual needs of [users].

4. Good Practices guidelines will ensure that the best possible and the most effective service is given in a timely and cost effective manner.

5. Having Good Practices guidelines will result in the improvement of the quality of client - provider communications.

6. It will lead to better access to mental health information by service users and the community at large.

7. It will enable the community and the users to make informed choices from a spectrum of available services.

8. It will bring greater accountability and transparency in the mental health sector.

9. It will lead to the creation of new services and ensure that the service providers will make many alternatives to existing services available.

10. There will be more satisfied users, if both medical and non-medical workers assure good practices.

11. Good Practices will lead to the optimal use of available resources and the creation of new resources.

12. It will ensure that the human rights [of users] are protected, including protection from unsafe and hazardous practices.

13. Good practices will ensure a pathway for the speedy and appropriate redressal of [users’] grievances in case of violations.

14. Having such guidelines will result in a greater professionalisation of the mental health service system, bringing in more tools and instruments for the proper delivery and the monitoring of services.

15. It will enable an environment for the creation of a variety of new service options.

16. It will lead to more research in the field and creation of evidence base, especially on the social determinants of mental ill health and the effectiveness of a variety of mental health interventions, both medical and non-medical.

17. It will motivate all mental health workers, both medical and non-medical, to upgrade their knowledge and skills.

18. It will result in a greater clarity of roles and the better integration of all professionals in mental health service delivery.

Values
The list of values upheld by the consultants in the Round Tables in the context of their clinical work were as follows:

- In the interest of the patient
- Respect for the patient
- Dignity
- Trustworthiness
- Safety
- Confidentiality
- Empathy
- Transparency
- Equality
- Accountability
- Commitment to rational and evidence based practice
- Self determination
- Autonomy
- Unconditional positive regard
- Respect for diversity
- Liberty
- Inclusion
- Integrity
- Competence
- Social justice

However, there was no objective way of knowing whether one is following one’s values or not. This could be a matter for debate and opinion. The demonstration of the values in practice was necessary in order for a clinician to be able to confidently state that a good practice has been achieved. There was no way of knowing about the quality of practice, without having the necessary awareness of concepts and skills in ethical problem solving and monitoring one’s own work from the ethical point of view.

Characteristics of values

Working with values is a skill, just like learning a behavioural or clinical technique. Clinicians have to observe their own practice and look for examples of values they believe in and also its implications in terms of specific clinical behaviours.
Values can be conflicting personally, and between stakeholders. It is a challenge to negotiate and balance values in such a situation. How do we negotiate values amongst the different stakeholders? How do we assure the adequate representations of different perspectives? How do we prioritise values? Who decides that? These are some of the important questions involved in any value dilemmas.

When there are conflicting values (e.g. safety versus autonomy), it is necessary to objectively articulate and resolve the issue. The following were said to be the important analytical steps in resolving the dilemma:

Core values driving the MH sector
The Mission Report had posted the following as the core and subsidiary values driving the mental health sector.

Examples of value dilemmas

Principles of good practices
A list of principles of good practice were derived from the values, and the areas for operationalisation were developed. 9 principles and 24 areas of operationalisation were derived in this way. The principles were discussed by the group.

Principles of Good practice and Areas for operationalisation

Wellness

Principle 1
Care and treatment provided will match the individual needs and will be in the best interest of the client.

Areas for Operationalisation

Principle 2
Every client will be offered a variety of proven, effective treatments.

Here there was a discussion about findings, which are not proven by research but are yet found to be effective. Example could be that of a qualitative research which has drawn its conclusions from 5 cases and may not have followed rigorous quantitative methodology. What should we do with such a data? IPS for example, has not looked at the data published in social science field. A multidisciplinary nature of the group present for good practice consultations will help exchange of such data and ideas.

Areas for operationalisation

Principle 3
The client’s holistic health will be considered in delivering appropriate care and treatment.

There was a discussion about what is meant by the term holistic. Some participants felt that issues of spirituality and social context should also be added to the list. While some others felt that the term holistic means inclusion of services related to the field of health.)

Areas for operationalisation

Participation

Principle 4
Steps will be taken to facilitate and ensure client participation in the care and treatment process including design, plan and implementation of program

Dr Davar commented that participation is a difficult issue especially in the context of institutionalization. However we must remember that there are degrees of participation. So even though we may not always ensure complete participation, we may talk of enhancing it.

Areas for operationalisation

Principle 5
Services will be accessible and affordable.

Areas for operationalisation

Non-availability of trained professionals is an important issue. Training Institutes produce only 5 psychiatrists per year in Gujarat. Rural areas virtually lack any mental health services. Overcoming these difficulties is a big challenge. We do not have good training opportunities. As far as the field of health is concerned, we have had a movement from dispensary to community. We need such strong movements in mental health sector as well. Strengthening primary health services is another possible solution.

Safety

Principle 6
Care and treatment settings will ensure safe environments for clients.

Areas for operationalisation

Honour

Principle 7
Culturally appropriate treatments will be provided in the best interest of the clients.

Areas for operationalisation

Autonomy

Principle 8
The client will lead the choices made in her / his own care and treatment.

Areas for Operationalisation

There was a discussion to define the term consent. Many felt that its a western concept and needs further exploration and education.

Justice

Principle 9
Service settings will protect the civil, political, social, economic and cultural rights of clients.

Areas for Operationalisation

The way forward
The participants discussed the central themes and suitable dates for the next four sessions. Suggested themes were as follows:
1) Institutional care
2) Community care and rehabilitation
3) Care and treatment
4) Medical evidence and certification

Four subsequent consultations were held on these themes through September – December. In all over 50 consultants participated in these Round Tables from all sectors in mental health, Gujarat. Reports were eventually made of the proceedings and submitted to the MHSP office at IIM, Ahmedabad.

Acknowledgements:

We thank:
All the participants and the resource persons;
Ahmedabad Management Association for the excellent conference facilities provided for the consultations;
The Indian Institute of Management / MHSP / the MHSP Reference Group for financial and other support to our work.

Bapu Trust is interested in facilitating other such good practices workshops and consultations in the rest of the country, in partnership with local organizations. Do contact Dr. Bhargavi Davar with ideas or proposals on this subject at wamhc@vsnl.net or info@camhindia.org