Child and Adolescent Psychiatry in India Part 6: Behavioural techniques

There are a wide variety of therapies that attempt to help patients and families improve their emotional health and well-being. We know from evidence that the most important factor effecting therapeutic outcomes is the quality of the relationship with the therapist. It is easy to become overly attached to one model, particularly if it fits the therapist’s way of thinking and has helped them personally. An overly confident or rigid belief in one’s own model may serve as an omnipotent defence against the anxiety we face acknowledging the limitations both individually and within each model. Finding the right ‘fit’ of treatment for each patient and family is essential. The models of mind I gravitate towards are grounded in psychoanalytic theory, particularly in its current developments linked to research and neuroscience. I also practice mindfulness based cognitive therapy, which despite its name, dove tails well with psychoanalytic ideas. Mentalisation based therapy which has a psychoanalytic foundation is another useful model I commonly use. While these are the main framework for how I formulate clinical problems, I have also used behavioural techniques, seen CBT cases and worked alongside family therapists.  I appreciate how easily all of these different terms and therapies can leave patients and families feeling lost.  I will explain how I have used some of these approaches to assess and treat children in Kolkata, and in doing this explain some of these therapies more fully. I will begin with the behavioural techniques.

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All pictures provided by Martha Swann

Behavioural models of therapy focus on learned behaviours with a detailed analysis of how environmental factors shape them. There are a number of parenting courses based on this model and these teach parents practical tips on how to improve their relationship with their child and how to introduce appropriate and effective boundaries. Parenting courses such as these have excellent evidence for treatment of childhood disorders such as ADHD. I have previously attended a course on the ‘the incredible years’ strategies and some of these techniques have proven very useful when working with the parents at Calcutta Rescue. This method provides a hierarchy of interventions for parents to manage problematic behaviour. It also instructs parents on how to take part in non directive creative play, with evidence on how this can reduce difficult behaviours and strengthen child-parent bonds.

I have now worked with approximately 40 children and families at CR schools and found only 1-2 examples of parents playing with their children. Only a few more praise their children or demonstrate an ability to vocalise positive characteristics. The majority unfortunately neither played or praised. It was also common for parents to label their children as ‘bad’ or having no positive attributes , a painful disclosure to hear. The absence of play or praise in relationships appears to be partly cultural and partly a result of the harsh socio-economic circumstances they live in. It was common for parents to describe what I would consider to be quite normal care and attention, as the child being ‘pampered’ and a concern that this may adversely affect their development.  This fits with the cultural practice of encouraging interdependence and obedience over individuality and autonomy seen in western cultures. At other times however, it was clear that abject poverty, or drug and alcohol abuse in the families had led to the cycle previously described in my blogs, with little positive emotions and experiences being shared and nurtured. The behavioural techniques I found to be most effective, were those I used to address cases of physical punishment. In these families I began by being as direct as possible in educating the parents on the negative effect of violence on the emotional development of their child.  Parents frequently admitted how this form of punishment was rarely successful in the longer term, with children becoming ‘more stubborn’. Interestingly these parents were often unaware of how to set boundaries for their child. In the incredible years, the second tier of intervention is to encourage desirable behaviours through a system of rewards. These rewards do not have to be material and can be things such as time spent with a parent. Introducing concepts such as play, listening, praise and reward systems were normally only possible in a wider a context of working on the relationships and dynamics within the family which I will cover later. Given the time restraints and the seriousness of the violent behaviours, I focused on trying to swap the violent strategies with the highest tier of intervention- that being ‘consequences’. Consequences need to be immediate, age-appropriate and if possible, given with advance warning. Parents were able to identify appropriate alternative sanctions, such as taking away certain privileges and it was common for my suggestions to appear as a completely novel concepts. Striking a balance between making clear to the parents how harmful physical punishment is and preventing the parents from becoming excessively guilty and withdrawing from treatment, was a difficult line to tread. Many of these techniques come naturally to the majority of parents in the UK, although there are still many lessons that all parents may find valuable, such as the difference between rewards and bribes, and the importance of certain techniques such as ‘time out’ being used in a thoughtful and calm manner.

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Motivational interviewing was another behavioural technique I found useful. This is a method for ‘facilitating and engaging intrinsic motivation within the client in order to change behaviour’. I most commonly used this to help adolescents at Calcutta Rescue’s schools to think through their hopes and plans for the future. Nearly all students initially stated hopes and aspirations for the future which were unrealistic. For example, older students would speak about wanting to be a government official or doctor when their grades were consistently poor. Others would talk of wanting to own a tea stall, while at the same time speaking about how they hoped to move out of their slum accommodation to secure a better quality of life. Motivational interviewing recognises that telling an individual to change a behaviour that you believe is harmful or unhelpful, may only serve to increase resistance if the patient is not in a position to change. As such, it is more effective to help a patient reflect on their current situation and highlight both the positive and negative aspects of their current position, while ‘rolling with resistance’. You then work on helping the patient to face these areas of conflict and find solutions themselves, so for example, I would encourage adolescents who spoke of wanting to own a tea stall to consider their prospective earnings and and contrast this with their other aim to improve their living standards.

These two behavioural approaches are examples of fairly straight forward techniques that were useful for many of the children and families at CR. You did not have to look far into a child’s family life to frequently find complex and unresolved trauma however. A common example of this was the loss of a key family member through sudden death. In my next blog I will discuss how more complex models and approaches were needed for such cases.

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Child and Adolescent Psychiatry in India Part 5: Can mental health professionals make a difference?

In my past few blogs I hope to have conveyed the terrible social circumstances faced by the children at Calcutta Rescue’s two schools.  The primary goal of Calcutta Rescue is to provide these children with a safe environment where they can be looked after. Where does one begin in examining a child’s emotional life when they are returning to an abusive and deprived environment each day? Would it not be better to concentrate on improving their social situation before attempting to heal the emotional scars left behind?

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All pictures provided by Martha Swann 

In my opinion, the relationship between social circumstances and mental ill health are inextricably linked, thus both areas should be address in tandem. When I arrived in Kolkata and saw the families living in squalid conditions opposite the school, I suggested buying land and creating low cost housing for the families. I quickly discovered that this would not work. Communities are resistant to having slum dwellers move into their area as they are seen as undesirable. If land is found in a location that is affordable the families are of often displaced from their community, far from their place of work. Similar projects attempted in the past have failed, with families eventually choosing to move back to slum accommodation. The terrible living conditions and chaotic lives of the people in the slums are not likely to change in the foreseeable future and cannot be easily solved. With this in mind attempting to improve the emotional health and well-being of the families is a essential if these children are to be equipped with the means to change their lives in the future. The sense of hopelessness and despair that is easily felt when hearing the stories of many of these families is part of what makes providing support so difficult. Without a team and linking services to share the emotional burden of the work, it is an extremely tough task.

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In the most part, staff within an organisation that regularly comes across very disturbed states of mind use a variety of defence mechanisms to manage. The psychiatrist and psychoanalyst Rob Hale has written a paper on the various forms of defence commonly seen in doctors who are ‘faced with the task of turning the unacceptable into the mundane’.

I recently met a volunteer who was involved with a similar school to Calcutta Rescue. They employed a school counsellor who soon reported regularly disclosures of sexual abuse. The children told stories of being groomed by adult men in their area, however with no recourse to effective child protection agencies the school felt powerless to intervene. The volunteer was clearly traumatised by the experience. Given that the school felt they were unable to keep the children safe following such disclosures, they made a decision to stop the school counsellor. I speculate that the need to deny the reality of the children’s lives was a defence against the unbearable truth of what was happening. Without the option of a school counsellor the children lose an opportunity to process the experience and form a coherent narrative around the events.

Science is now beginning to show how talking therapies lead to changes in the structure and connectivity of the brain. Labelling angry or frightening emotions with words has been shown to reduce activity in the amygdala (the brain’s fear centre) a feature of emotional regulation. Studies have also shown that developing the ability to put emotional difficulties into words not only facilitates affect regulation but also improves executive function (an umbrella term for the management of cognitive processes). We also have evidence that those who go on to do well as adults following severe adversity and abuse, are those who are able to develop the capacity to form coherent and reflective narratives about their experiences. So if an organisation is able to bear the pain and anxiety of the stories they hear, they still can offer an important intervention through effective therapy.

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We must be realistic about what is possible in each situation however. It would be far better for a school to continue providing care and support to children, than to attempt to take on complex mental health issues without appropriate guidance, which could easily lead to the staff or organisation as a whole becoming sick. My own personal experience has been to adapt my model from the UK and adjust it accordingly to fit outcomes that are realistic with each patient. In the longer term I hope to be able to support the work from the UK via supervision on skype and if possible, collaborate with other interested mental health professionals. In this way the school will have an opportunity to offer therapeutic treatments with outside support and expertise.

My next blog entry will detail some of the different models of the mind I have used to work with the children and families at CR schools.

If you are a mental health professional and interested in getting involved please email me at admin@calcuttarescue.org

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Child and Adolescent Psychiatry in India Part 4: Attachment Theory in the slums of Kolkata

In the not so distant past, academics and clinicians alike debated the relative influence of the environment on the developing mind. At one extreme were those that saw the mind as a ‘tabula rasa’ stating the mind was completely shaped by the environment and experience. At the other were those who believed the child’s innate way of being was the deciding factor. We now know a child’s mind develops through a complex interaction between their environment and genes, with both playing a crucial role. So for example, the presence of a certain gene responsible for reduced levels of an enzyme monoamine oxidase A (MAOA) in the brain places you at greater risk of developing aggressive and antisocial personality traits as an adult. However, that risk is only realised when that child grows up in an abusive or traumatic environment.

One area of child development that is predominately effected by environmental factors is that of attachment theory. Attachment theory conceptualizes the innate primal drive that all humans are born with – to make contact and maintain proximity to primary caregivers, commonly the mother or father. Healthy attachments are as important for the child’s emotional and social development, as food is to the developing body. The ‘strange situation’ test is a way of categorising a 1 year old child’s attachment into one of four groups: secure, avoidant, ambivalent and disorganised. Children with a secure attachment have been shown to do better across varied measures including managing complex emotions and understanding others feelings, while children with a disorganised attachment are at increased risk of a range of psychopathologies throughout their life span.  The adult attachment interview is a research tool that analyses an adult’s style of describing their own childhood and attachment figures. Adults can then also be categorised into one of four groups: secure-autonomous, preoccupied, dismissing and unresolved-disorganised. Interestingly, when an adult caregiver’s attachment status is categorised, one can then accurately predict what the attachment status of their unborn child will be in the ‘strange situation’ test at 1 year. My very brief coverage of one aspect of this burgeoning area of fascinating research is to attempt to give a flavour of how child mental health workers go about making sense of the way in which children present, and how we ground our treatment pathways in developmental evidence.

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all pictures provided by Martha Swann www.marthaswann.com/blog/2015/02/15/calcutta-rescue-number-10-school/

As I have previously described most of the families at Calcutta Rescue’s two schools live from day to day, with the pressure of survival being the primary concern. Trauma, violence and other forms of abuse are common place, all of which make secure attachments a rare occurrence. A short interaction between a caregiver and her child that I saw while walking on the streets of Kolkata is a good example of the type of problem I commonly hear about in the school. During this interaction a mother who lived on the streets was telling off her 2 year old son. The mother was shouting at the toddler whilst holding a wooden stick. The little boy was crying and slowly taking steps towards his mother. She responded by shouting and raising the stick. The little boy looked terrified and stepped back, paused and then started to move towards her again. Throughout this time the mother was smiling at her friend. At this point I intervened.

The little boy presented to his mother as distressed, angry and frightened.  His attachment system was activated, and as such he looked to seek proximity to his mother for comfort and for help to make sense of this bewildering experience. His mother responded by threatening him with violence, as a result his ‘fear response’ was activated and he moves away to safety. These conflicting systems and messages cannot be brought together, as a result a confused and chaotic experience is taken into the child’s mind, at a deep and preverbal level. If this is the predominate dynamic, over time the child would struggle to learn how to manage his own feelings and develop a coherent sense of self. While I appreciate this may appear overly critical of the mother, it is important to stress that this is not meant as a judgemental or blaming exercise.

I know from speaking to many different families, as I wrote in my last blog entry, that physical abuse is a common occurrence for families living in the slums. The parents of the children I have seen, almost invariably have their own stories of abuse and violence. These parents have developed a tough and dismissive attitude to their own pain and vulnerabilities in order to survive. I have frequently seen parents laugh when their children have broken down in tears during consultations. While this laughter could superficially be seen as deliberately cruel or unloving, I have found this to be a brittle defence against their own unresolved psychic pain and trauma. Without a kind and reflective attachment figure to help them name and process their own unbearable mental states, they remain buried, making it almost impossible for them to identify with their child’s distress and vulnerabilities.

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We must not despair or feel defeated however; we now understand that a secure attachment can be ‘earned’, through psychotherapy or other positive experiences. This is something every person working with young people (or adults for that matter) should keep in mind and is one explanation for why the single best predictive factor for a good outcome in therapy is the quality of the relationship with the therapist. That is not to dismiss the importance of clinician having a good training and sound understanding of the model they use, but it is essential that the founding principle underlining any therapeutic work should be a kind, reflective and compassionate stance from the professional in question. This gives a person an opportunity to take in something different and alter their way of relating both to themselves and others.

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The primary objective of Calcutta’s Rescue’s schools has been to provide a way out of the slums through education and higher training. There is a hope the children will then secure jobs that can lift them and their families out of the cycle of poverty and destitution. While there are a small number of children that are extremely gifted, the majority of children continue to have enormous odds stacked against them.  Living in one room means they routinely have no private space or no desk to work on. They also are unable to go to bed in a separate quiet room, staying up with the adults, causing many children to be chronically tired. Free education is at least theoretically offered to all children in India. In reality the very poor and uneducated families are unable to fill out the necessary forms or understand the process of enrolling children into the free government schools. Calcutta Rescue allows children from the slums to have 1 to 2 years to adjust to the format and structure of school before starting in the government system. The government schools attended by the children at Calcutta Rescue run for approximately half a day. The level and intensity of the teaching in the government schools is unfortunately not enough to allow even the most able children to achieve the required grades for further education. As a result, Calcutta Rescue provides an extra half day of tuition to all children 6 days a week. In my opinion however, it would be a mistake to focus on the academic performance of the children as the primary outcome measure of the schools success. Even if the children are not able to achieve at a higher level of education they ultimately take something equally valuable away from their experience at the school. A specific example can be seen in a student who explained how she coped with her horrendous home situation through knowing she could speak with one of the teachers who had been a great source of support to her.  Another less direct example can be seen in two of the mothers who I have met with, both of whom had attended Calcutta Rescue as children. While they had not been able to break out of the cycle of poverty, their ability to reflect on their relationships and discuss their feelings was markedly different from other parents I have met with. The best evidence I have however, which I am unable to capture in objective data, is the atmosphere in the school. There is a warmth and enthusiasm from the staff that can be seen and felt when spending time in the two buildings. Particularly important is the determination of the head staff- Monami, Jayati and Baishakhi. The CEO of the charity Saira also takes an active interest in the day to day running of the schools and teaches English on a Saturday. I have no doubt that each of these senior staff could easily work in less challenging schools, with far more facilities and better pay, but they  instead choose to try and change the lives of children and families that are so often forgotten- something I have a great deal of respect and admiration for. It is this commitment of the staff to the children’s well-being that links the concept of attachment to the success of the school. While many of the parents fight for survival, the staff give the children an experience of a different kind of relationship, one in which they are thought about, encouraged and treated with kindness. These experiences can allow for a coherent and compassionate sense of self to develop, with lasting implications for the developing mind of that child and potentially future generations.

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A previous volunteer remarked how healthy and happy the children looked in the school. They were then both appalled and shocked when they were taken to some of the homes of the families, with one little girl living under the stairs of a nearby public bridge. The physical health of the children is a result of having a home at the school that feeds, clothes and nurtures their development. While I now know that beneath the smiles and laughter, often lies a great deal of pain and uncertainty, the impact of this school on these children’s lives is something I am sure will stay with me, long after leave Kolkata. I also hope that I can continue to support the school in whatever way I can, to make sure more children are given the chance to find out there can be more to life than simply surviving.

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Child and Adolescent Psychiatry in India Part 3: A cycle of violence

In the UK a child and adolescent psychiatrist is one member of a much larger mental health team, comprising of psychologists, psychotherapists, family therapists, social workers and mental health nurses. Together they assess and treat children who suffer from a wide range of emotional and behavioural difficulties. A child and adolescent psychiatrist is more likely to assess and treat patients with more serious or complex problems, particularly if they are at high risk of harming themselves or have a neurodevelopmental disorder such as ADHD or autism. They are also more likely to be involved in cases where the children have experienced serious abuse or highly adverse social circumstances. With this in mind, it is safe to say that nearly all the children attending the two schools at Calcutta Rescue would fulfil the criteria for being assessed by a child and adolescent psychiatrist in the UK.

The provision of mental health services in India is extremely poor as recently reported by the bbc and guardian. This is partly related to the stigma of mental illness leading to poor investment, with few initiatives to recruit and promote better services. As such my co-therapist and I have no recourse to refer on to other services for further support or interventions. One of the the most challenging aspects of working in isolation in this way is managing cases of physical abuse. The vast majority (approximately 80%) of the children I have seen in Calcutta Rescues schools report being regularly ‘scolded’ by their parents. When asked directly about what this ‘scolding’ entails, most minimise the punishment.  However, the true nature of these ‘scoldings’ have emerged through the narratives of their lives, with these incidents often turning out to be far more frequent and severe, including parents using implements such as wooden sticks.  Where children are living in abusive environments the threshold for acting to remove that child from their carer is extremely high. The local police have a reputation for corruption and brutality, while the local government run children’s homes are overwhelmed. As such, removing a child from a family could easily increase the risk to the child. Calcutta Rescue attempts to engage struggling families and offer support where possible. The school also provides a safe place where their physical and emotional development can be monitored.

Corporal punishment, defined as violence inflicted on children in the name of ‘discipline’ now has over 150 studies demonstrating a wide range of negative effects, with no positive outcomes. For example, children punished by their carers with violence are more likely to be aggressive, take part in bullying behaviours and have lower levels of empathy towards other children. There is also evidence  that these effects are pervasive with children being more likely to act violently as an adult. The effects on the children I have seen has been variable. The most worrying presentations are those children that appear to be frozen by a fear they will say or do something wrong. These children are commonly highly anxious when a family meeting is proposed, concerned this may lead to further ‘scolding’. As described in my previous blog, the socio-centric nature of Indian society means children will normally demonstrate a more interdependent way of being with high expectations of obedience. I have thought carefully about this in dialogue with my co-therapist (who has grown up in Kolkata) and it is clear that these reactions go beyond what could be thought of as cultural norms. It has been very difficult to move these children to a place emotionally where they feel able to express themselves. The family meetings have been more successful, with parents speaking openly about their lives and experiences.  I have also been able to gently approach the use of physical punishment. In general the response has been the same, the parents understand that their children are frightened of them but they believe that it is necessary if they are to develop respect and obedience, and this is how they themselves have been brought up.

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The social situations undoubtedly play a significant role in the frequency of this violence, with families lives primarily being focused on survival and traumatic loss being commonplace. Inadequate accommodation, poor diet and physically challenging occupations all contribute to low life expectancies. In many families the father earns a living through pulling a hand drawn rickshaw. This back breaking work pays around 100 Rupees (approximately £1) a day. Most of these rickshaw pullers are so poor they do not own shoes. If the main breadwinner falls ill, the family can face a grim scenario of complete destitution. Stories are not uncommon of family members borrowing money to pay for expensive medical care, only further embedding them in a cycle of poverty and destitution. When parents are faced with such harsh and unpredictable conditions, there is very little room for relationships and emotions to be given the time and attention needed. A lack of education also results in the parents having less developed skills in problem solving and thinking through parental strategies that do not rely on violence. Parents may have no experience of a kind and thoughtful adult to use as an example for how they can approach parenting. This is where Calcutta Rescue school presents an opportunity to break this pattern, offering a different kind experience. I will describe and develop this concept in future blogs.

Another important contributor to the violent narrative running through many of these family lives is their position in society. Most are migrants from poor rural areas in West Bengal or illegal migrants from other countries, such as the nearby Bangladesh. These groups are stigmatised and have grown use to being treated as second class citizens by other members of the community and government officials. For example, near one of Calcutta Rescue’s clinics there are around 30 families living under plastic sheets in slum accommodation on a publicly owned park. The families I have seen at the school all report how ‘bad people’ hang around at night and although few elaborate further, some have described that these people are normally drunk and verbally abusive. All the children and parents have stated how much they dislike living in the park with the constant threat that the government will demolish their homes which are deemed as ‘illegal’. The families cannot look to the police for support or protection, and described how in previous years for the holy festival of ‘Durga Puja’ the police came with sticks and smashed or burnt down down the slum structures, loading any belongings left behind onto a lorry. The space was then used to display lights and Pandels for the holy celebration. At the end of the festival the families moved back. If these people are treated as worthless by society, there is little hope they can then develop a sense of concern and compassion for themselves and their children. Fortunately some families report the situation has improved slightly in the past year, which I understand is the result of a local politician advocating for them. While this is a step in the right direction, the families and children continue to live with a deep sense of uncertainty about the stability of their situation and within the consultation room show the mental scars from having been forced to live with the threat of abuse for so many years.

There is no easy solution to these problems. My initial work with families leads me to believe family work can provide a useful space for parents and children to think about their emotions and relationships for the first time. Behavioural interventions and techniques are commonly completely new concepts to parents and with time I hope to gain a sense of whether they are able to be retained and used at home. Changing how society views these people is perhaps the most difficult problem. This is an extreme example of a problem that is present everywhere, with the UK being no exception. Whether it be ‘the Romanian’s’ who were reportedly going to flood the UK and take ‘our’ jobs, or Muslims, who are brandished as terrorists because of the actions of a small minority of disturbed extremists, the underlying psychological processes are the same. I hope that sitting with those who are suffering, listening to their stories and bearing witness to the injustice will form part of gradual process towards ensuring these people receive the same opportunities and respect that we all have the right to demand. When first researching about Calcutta Rescue I read on their website how they serve ‘the most socially and economically disadvantaged people in the region- regardless of gender, age, caste or religion’. After spending time working alongside other staff at Calcutta Rescue, this statement now has a new meaning to me.

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Calcutta Rescue Sports Day 2015

Please enjoy some video footage I’ve put together from the Calcutta Rescue sports day:

http://vimeo.com/116410388

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Child and Adolescent Psychiatry in India Part 2: Egocentric western societies and psychological space

At the Tavistock in London, we regularly speak of the importance of the therapeutic space. The patient and family must have confidence in a private room and time that is protected. This in turn allows a psychological space to develop, where a patient has the opportunity to share their most private thoughts and feelings in a safe and confidential environment

My expectation when coming to India was that this view of privacy and space would be understood as an important precursor to a therapeutic process. After arriving in Kolkata I went to a well known government psychiatry hospital  to try and establish a link. When I found the psychiatry clinic, there were three psychiatrists sitting in a small room with a queue of 20-30 patients stretching back out the door. The start of the queue began inside the room and each of the three patients being seen were a few feet apart. At another hospital I observed a psychologist reviewing patients.  The space offered for consultation was somewhat more private, but patients and staff still walked in and out of the room every few minutes. My description of these practices, is not to pass judgment or deem my techniques and training as ‘better’ or ‘right’ but to acknowledge there are stark differences in the cultural expectations of what constitutes a therapeutic setting.

Admittedly, my own understanding of privacy and psychological space has been developed in western society. Western cultures are mainly ‘egocentric’ and emphasise the importance of the development of the ‘autonomous self’. ‘Sociocentric’ cultures, such as India view the primary goal of development as the need to be increasingly dependent on others. As explained in Graham Music’s book ‘nuturing natures’, sociocentric cultures are more likely to promote control, compliance, co-operativeness and interdependent ways of being, as opposed to individuality. These are characteristics I have repeatedly seen during consultations and it has not always been easy to separate the effect of cultural differences from emotional problems caused by social deprivation and family conflict.

All of the 16 children I have worked with in India have the worst social situations I have come across in my career, without exception. The majority of children live in extremely overcrowded conditions as a result of poverty. They commonly sleep in a room with 8-10 other people.  One patient described how 14 family members slept in one small room. Regardless of cultural practices, these children are given no opportunity to develop a concept of privacy, being exposed to every parental argument or act of intimacy. Problems or difficulties within a family home are also quickly spread throughout the tight knit communities.

Photo of a mother of a student taken outside her home near Tala Park school  (taken by my colleague Sarah- http://indianhoneymoon.wordpress.com/2014/12/05/tala-park-school/)

Photo of a mother of a student outside her home near Tala Park school
(taken by my colleague Sarah- http://indianhoneymoon.wordpress.com/2014/12/05/tala-park-school/)

Despite cultural differences, I believed it would be important to start the work from my own model of training and hoped this would offer a unique opportunity for children to explore their thoughts and feelings. I have attempted to remain open to how this model may be less effective in a sociocentric culture and will offer further reflections as I continue this blog.

Part 3: coming soon

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Child and Adolescent Psychiatry in India Part 1: Volunteering for an NGO

I recognise I am fortunate to have been born in a country where a free health care service exists with high standards of training and care in mental health. Volunteering in a developing country provides a unique experience of another culture and health care system.  It also represents an opportunity to share skills and provide care to people that have no access or expectation of such support. When looking to volunteer abroad as a child and adolescent psychiatrist my options appeared to be limited. Many advised the language barrier would limit the effectiveness and scope of any work. Child and adolescent psychiatry is also a relatively undeveloped area of health provision in many developing countries. While these two points are relevant and there are many challenges to this work, having started mental health projects through the charity Calcutta Rescue, I can see that child and adolescent mental health professionals are needed, and there is potential to do extremely important and rewarding work.

In the past month, I have started to use twitter to try to connect with other mental health professionals to link them to this blog. I hope by sharing my experience of volunteering abroad I will encourage others who are thinking about such a move. I also hope I can provide honest feedback on which skills are transferable and what are realistic expectations. While I will consider this blog a success if just one person decides to volunteer abroad, ideally I would love for the work to continue at Calcutta Rescue, with other mental health professionals volunteering in the future.

School

The beginning

A difficult point was raised at a meeting with the CEO and the senior staff at Calcutta Rescue’s two schools. A small number of children had persistent poor attendance despite various interventions by the school. There was a question as to whether these children should be excluded, as places at the school are in demand and resources scarce. This seemed logical but the management wanted to make sure they were doing what was in the best interests of the children. It was agreed that any child that was being considered for exclusion would first be assessed by me to determine why they were not attending.

The importance of getting these assessments right weighed on my mind for the next few weeks. Outside my flat lives a family with a young child. The father and mother sleep under their hand drawn rickshaw and the little 5-7 year old boy sleeps next to them on a piece of cardboard. It is a distressing sight and a painful reminder of the desperate level of destitution and poverty in the city. The families at CR live in similar conditions, albeit they normally have a some sort of structure to sleep under, even if this is just a simple sheet of plastic. What would be the effect on a young developing mind, growing up in these conditions? What would be the reasons for a child’s non-attendance at a school? Surely very different to what I may expect to see in the UK. Would my own experience and understanding of the world be so far removed from these families that I was being naive to believe I could make a difference?

Part 2: Egocentric western societies and psychological space (link at top of page)

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Chitpur Leprosy Clinic Video

Some video footage from my visit to the Chitpur leprosy clinic a few weeks ago. Humbling stuff.

(please skip past the minute of missing video at the intro- for some reason this part will not upload- fortunately the most interesting parts are still present)

http://youtu.be/NtCvmr0dF50

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Extensively drug resistant Tuberculosis (XDR-TB), the next epidemic?

The WHO’s statistics on tuberculosis (TB) make for alarming reading. In 2013 9.5 million people were diagnosed with the disease and 1.5 million died. In the same year 480,000 people developed multi drug resistant tuberculosis (MDR-TB) with an estimated 210,000 dying from the disease, representing a three fold increase in cases from 2009.

What is TB?

Tuberculosis is caused by the bacteria Mycobacterium Tuberculosis. A very slowly dividing, lipid covered bacteria.

How is it spread?

T.B typically attacks the lungs and is spread through the air when people with active T.B cough, sneeze, spit, etc.

CXR

Chest X-ray of a person with advanced tuberculosis: Infection in both lungs is marked by white arrow-heads, and the formation of a cavity is marked by black arrows.

How common is the disease?

About one third of the world’s population has been infected with T.B, albeit most of these cases now occur in the developing world. The vast majority of those infected remain asymptomatic and are not infective. This is called latent disease. About 5-10% of those with latent disease go on to develop active disease.

What are the risk factors for developing T.B?

Overcrowding, malnutrition, chronic lung disease and smoking are all implicated. Those infected with HIV are also at a significantly higher risk.

What is Extensively Drug Resistant T.B (XDR-T.B)?

XDR-T.B is just as the name suggests, it is T.B infection that is resistant to most antibiotics known to the treat the disease. 100 countries have now confirmed cases of XDR-T.B.

Why has XDR-T.B occurred?

The main cause of XDR-T.B is improper use of antibiotics, either through erratic compliance or courses of medication being stopped early. This has gradually lead to ever more resistant forms of the bacteria developing.

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WHO data on the number of patients with laboratory-confirmed XDR-TB started on treatment in 2013

Should we be concerned?

In short, yes. Beyond the obvious widespread suffering and mortality caused by the disease in developing countries, this new form of the disease threatens to turn the clock back to a time when T.B represented a commonly fatal infection in all parts of the world. The first reported case of XDR-T.B was in 2006, the disease is now known to have spread to over 100 countries.  It may be hard for wealthy western countries to accept that this situation is the result of poor investment in the fight against TB, which has often foolishly been seen as someone else’s problem.

What is being done?

Work by organisations such as the WHO and more investment in services is beginning to have an effect with access to TB care expanding substantially since 2000 with an estimated 37 million lives saved. The WHO estimates however there is still a funding gap of US$ 2 billion per year to fully respond to the TB epidemic in low- and middle-income countries.

What is Calcutta Rescue’s role?

Calcutta Rescue provides a DOTS (directly observed treatment schedule) in both urban and rural areas around Kolkata. This programme runs 6 days a week and ensures patients diagnosed with T.B are registered and monitored. This type of work is crucial to ensure effective treatment is provided and to prevent the development of further multi drug resistant cases. Despite the success of the DOTS programme there is still evidence of non compliance in around 6-30% of treated patients. The importance of the programme achieving a 100% completion rate is well understood. Recent research has provided evidence for the effectiveness of technologies such as pill dispensers. However the WHO gold standard pill dispensers are expensive and only dispense tablets, rather than medication sheets.

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Dr Deb (left) at a meeting at the Tamuldah clinic (below) to discuss the CoxBox program with the local DOTS team

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What Calcutta Rescue is doing to address the problem?

Calcutta Rescue has teamed up with a group of doctors to produce the CoxBOX (a project funded by IKP Knowledge Park, the United States Agency for International Development and the Bill & Melinda Gates Foundation through the Grand Challenges in TB Control initiative). The ‘Coxbox’ is an affordable mobile technology based  pill dispenser capable of dispensing medicine strips, reminding patients to take their medication and alerting local clinical teams if the medication has not been taken. The device will also inform local teams when medication is running low.

Calcutta Rescue is committed to treating TB and stopping the emergence of drug resistant forms. The Coxbox project is an example of how Calcutta Rescue is able to respond to challenges in an innovative and dynamic way. Drawing on it’s own experience and infrastructure, while at the same time collaborating where necessary to secure funding and outside expertise.

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The prototype CoxBox design

To find out more, get involved or donate, please follow the link below:

http://www.calcuttarescue.org/

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Chitpur Leprosy Clinic

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My experience in the Chitpur Clinic for Leprosy patients:

I have now visited the clinic on two occasions, speaking to staff and patients. I was both moved and humbled by what I saw and heard. The patients sense of gratitude towards Calcutta Rescue was palpable, with many of them keen to tell me how grateful they are to the organization.  There is an acknowledgement that without this service they would have no where to turn.

It is relatively easy to see on a practical level how Calcutta’s Rescue cures patients of leprosy and prevents them from falling into abject poverty, perhaps less obvious is the vital psychological effect of the service offered. While working as a psychiatrist in the NHS, we often speak of the importance of a patient being ‘kept in mind’. That is to say, it is important for a patient to have a sense that another mind sees their distress and that they can respond appropriately. This is why above all things, the therapeutic relationship is key to good treatment outcomes. The leprosy patients at the Chitpur clinic have commonly experienced being rejected by family and friends having been viewed as diseased or tainted. The caring and supportive attitude of the staff at Calcutta Rescue gives the patients an experience of being both accepted and ‘kept in mind’, with their suffering being validated and responded to. Furthermore, Calcutta Rescue prevents the patients from losing their place in their community by helping with rent, repairs, nutrition and clothing. This alongside further education, helps family and friends overtime to understand their loved ones illness, rather than simply being afraid of it.

Although it is not as easy to show this with objective facts or figures, the evidence of the life sustaining relationship to the staff and organisation is easy to see, not only through the sense of community and warm atmosphere present in the clinic, but also in the moving expressions of gratitude when speaking to the patients about Calcutta Rescue.

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Patients at the Chitpur Clinic having their wounds dressed.

Leprosy in India:

Leprosy is a disease I first heard about in school, with terrible stories of how victims were forced to live as outcasts in leper colonies.  When later reading about Leprosy during my medical training, I considered the easily treatable and curable disease, to be more of a theoretical interest than an active problem.   This view very quickly changed when I became involved with the work of Calcutta Rescue. In 2011 approximately 250,000 people were thought to be infected with Leprosy around the world today, with 55% of these cases occurring in India.

So what is Leprosy?

Leprosy is caused by a bacteria called Mycobacterium Leprae. It is a bacteria that very closely resembles the bacteria that cause Tuberculosis.

How is it transmitted?

Leprosy is not a particularly infectious disease. It is thought to be spread through prolonged close contact and transmission through nasal droplets. Around 95% of the population is thought to have natural immunity to the bacteria. Most people who contract the disease are exposed to other risk factors including a poor diet, polluted water or already have another condition that compromises their immune system.

What happens when someone has leprosy?

The first symptoms of the disease do not normally present until on average 3-5 years after infection. This has been known to be as long as 30 years. Leprosy causes damage to the nerves in the legs and arms, leading to numbness and weakness. Without sensation such as pain, the patients can easily damage their bodies causing deformity and disability. These deformities are characteristic of the untreated disease and are also commonly responsible for the patients being singled out and ostracised from their communities.

How is leprosy treated?

Leprosy is easily treated with antibiotics, although a prolonged course is often recommended. Patients are no longer infectious after one month of treatment.

What is Calcutta rescues role?

Calcutta Rescue recognises the importance of a holistic and broad approach to treat and support those patients diagnosed with leprosy. The clinic not only plays a vital role in diagnosis and treatment, it also addresses the many problems associated with the disease. For example, many patients due to their disability or stigma are no longer able to work, Calcutta rescue ensure that these patients continue to receive basic nutrition, clothes and disability aids, such as crutches or wheelchairs. Patients can also receive support in covering their rental costs and their transport costs, enabling them t0 can travel to the clinic as necessary.

To find out more, get involved or donate, please follow the link below:

http://www.calcuttarescue.org/

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