By Peggy Sherrer

We’ve been in India two months. The halfway mark. That’s difficult to fathom given all that we’ve done and seen since arriving in late December. February was kind of a bust for blog writing mostly because our days were filled with presentations, training sessions, meetings, and laying the groundwork for our research project.

For those of you interested in our professional activities, this is a snapshot of what we’ve accomplished thus far during our Fulbright semester. If that doesn’t appeal to you, you can look forward to a post from Tom on his impressions of our life in Kochi.

Learning to Improvise as Fulbright Spouses and Project Partners

At the outset, we anticipated that we would be conducting guest lectures—individually and together—in different social work courses offered by our host institution, Rajagiri College of the Social Sciences. That hasn’t quite been the case. Our experience as married Fulbright scholars with a common interest in community mental health has been an improvisation à deux. Thankfully, we’ve discovered complimentary teaching strengths (insert audible sigh of relief here). Truth be told, Tom takes the lead as Dr. Content. Over the past year or so, Tom has been updating his two single-authored textbooks, Evidence-Based Practices for Social Workers: An Interdisciplinary Approach and Essential Skills of Social Work Practice: Assessment, Intervention, and Evaluation. He has reviewed and condensed more than 3,500 research articles. That’s “old-school” scholarship, to put it in Tom’s words.

I’m no slouch in the content department.  But even on my *best day* (and I’ve had 11 or so different course preps in my eight years of teaching various aspects of applied Psychology and Human Services), Tom astonishes me with his grasp of the mental health literature. I tip my coffee cup to him on a daily basis. I recently joked to a group of MSW students that it sometimes feels like a non-stop seminar at our house. They definitely got my drift.

On the other hand, I’ve assumed the role of Dr. Process. I contribute my share of content, but I’m more attuned to public relations, the one who makes certain everyone is heard, and considers the form and venue for teaching and training sessions. I’m the keeper of the MASTER CALENDAR, in caps here because it’s subject to constant juggling and revision. I take notes and write emails to ensure that key faculty and administrators are in the communication loop. I supervise our research assistant (more on that later). I’m a stickler for learning the names of all our students. I also set up our blog site, investing countless hours to teach myself WordPress. As a sideline, I’m the main trip planner.

When asked how we managed to pull off twin Fulbright grants, Tom is always quick to credit me as The Mastermind. Lest you think we’ve divided duties along gender lines, let me challenge that assumption by pointing out that Tom is Commander-in-Chief of food shopping, cooking, and housework.

Only once did I have the urge to cut Tom off—at the recent Fulbright Conference for all the South-Central Asia scholars where our joint presentation was to be delivered in 15 minutes. In full Dr. Content mode, Tom provided a lively introduction to our research project, Evidence-Based Mental Health Services in Kerala, India: Cultural Influences and Challenges. I was following with methods and concluding remarks. I’ll admit I was impatient for my turn so we could stay within our allotted time. Tick, tick. Perhaps it was my anxiety—I’m no fan of podium talks—but I was nearly tempted to shove him off the stage. 

Later that day, we participated in a round table discussion on teaching in India where a more relaxed atmosphere prevailed. This was an eye-opener for us because the Fulbright lecturers had markedly different experiences with their host institutions. Afterwards, Tom and I reiterated to each other what we’ve known all along: we’re very fortunate to have such warm collegiality from our colleagues and students at Rajagiri College. In particular, we want to recognize Dr. Mary Venus Joseph (pictured below), Dean and Administrator of the School of Social Work, for her unwavering support during our stay in Kochi.

Our Evolving Research Project

So what exactly does our research entail?

Our original Fulbright proposals described a joint research project utilizing qualitative methods to examine the development of mental health services in south India.  For those unfamiliar with qualitative research, it’s an approach to scientific investigation that seeks to answer questions from the perspective of a population of interest. It’s descriptive, textual and flexible, and is often employed to study culturally-specific information about values, opinions, norms, and social context within a given population. Commonly used in an exploratory vein, a hypothesis often is not formulated in advance.

The overarching goal was to document perceptions of progress and existing barriers to implementing evidence-based practices (EBPs) for treatment of serious psychiatric conditions such as schizophrenia, bi-polar disorders, and major depression. Briefly stated, evidence-based practice can be defined as interventions supported by the preponderance of controlled practice research. We hoped to gain understanding of how EBPs may be adapted within a given cultural context especially among psychiatric social workers that are emerging as key players in service delivery.

In our estimation, India was a model candidate for in-depth case study given its rapid growth on many fronts, including economics, technology, education, communications, and the advancement of an aggressive public health agenda. In particular, the treatment of mental disorders in India has become an important health priority in recent decades. As in many other parts of the world, effective service delivery in India is hindered by budgetary constraints, social stigma, and a shortage of adequately trained mental health personnel, especially in rural areas. There tends to be heavy reliance on religious and traditional healers to address psychological problems in many segments of the population. Based on our review of the literature, it appeared that so-called “Western” approaches to mental health care may be met with skepticism since these treatments often are at odds with prevailing cultural attitudes.

On the plus side, there have been promising strides in community-based approaches to address mental disorders and addiction. Particularly noteworthy is the work of Vikram Patel and his colleagues at Sangath, proof that mental health care can be evidence-based, empowering, and culturally sensitive. (A shout out to one of Sangath’s project coordinators, Dr. Neha Singh, an accomplished and charming woman we met in January at a conference on global health.) If you’re interested, check out Dr. Patel’s TED talk.  

Kerala, our home base, has much to boast about with respect to quality of life. The state has achieved the highest literacy rate in India with better overall health and longer life expectancies. Compared with other states in India, Kerala is considered a leader for enacting more progressive social welfare policies. Despite these positive advances, there are emerging mental health problems to be considered. Statewide, there is a lack of epidemiological data to determine prevalence rates of mental disorders in adults and children. There’s increasing concern that Kerala has the second highest suicide rate in India—roughly 2.3 times higher than national average, according to the Mental Health Authority. The state also has the highest per capita alcohol consumption in India with data suggesting a range of serious consequences, including a rise in alcohol-related traffic fatalities. The evolving mental health care system in south India provides a microcosm with larger global implications. As researchers, we wanted to learn more about innovative solutions that successfully balance scientific advances with respect for varying cultural beliefs and customs.

Two psychiatric facilities were recommended to us for our research, Kusumagiri Mental Health Centre in Kochi and Sacred Heart Hospital Paynkulam just outside the town of Thodupuzha. To date, we’ve done site visits to introduce ourselves at the facilities. In both cases, there was enthusiastic response to our request to conduct interviews with selected psychiatrists, social workers, psychologists, and nurses employed by the agencies. Although we’re not interviewing clients for our study, we were encouraged to spend time with them during our initial visits.

The agency profiles will include an overview of service delivery models and established assessment and treatment protocols. Specifically, we’ll be asking about level of awareness, acceptance, and capacity for implementing evidence-based practices. We’re also interested in cultural considerations in delivering treatment, the perceived role of social stigma as a barrier to help-seeking, the care giving role and burdens of family members, and perceptions of alternative approaches to mental health care, including the ancient system Ayurveda or use of religious healers.

Tom and I had planned to conduct all the interviews on our own, setting a modest goal of 24 practitioners between the two agencies, but for practical reasons we had to reconsider this approach during our initial weeks here. Early on, it became evident that language was going to be more of a challenge than we anticipated. Even though English is widely spoken, Malayalam is everyone’s first language so regional accents (ours and theirs) can make spoken communication somewhat difficult when discussing complex topics. We grew concerned that it would be too frustrating for our informants during the interview process if they didn’t fully comprehend what was being asked and vice-versa. For this reason, we modified our methodology to include a research assistant who could also act as a translator.

Fortunately, a highly-qualified individual was available and interested. Our research assistant, Indu Joy Panuthara, is an MSW graduate with experience in psychiatric social work. Indu is assisting with the coordination of the project, including training and supervision of the MSW students, and compiling of agency profile data. In addition, she will be providing translation when Tom and I are interviewing agency directors and psychiatrists.

The research team expanded yet again to include Masters of Social Work (MSW) students.  Ideally, this will be a valuable educational opportunity for the 12 second-year MSW students in the psychiatric social work concentration (see photos below) and their faculty advisor, Fr. Saju Madavan, MSW, Assistant Professor of Social Work. Thanks to Professor Saju, our modest research project has now evolved into a research practicum on qualitative interviewing and data analysis. Professor Saju has cultivated strong ties with mental health agencies and hospitals throughout south India. His collaboration has been invaluable. Not only did he help us select the agencies for our research, he also arranged for other field visits including a recent trip to the psychiatric unit at Ansar Hospital in Thrissur.

The MSW students under Professor Saju’s supervision are well-trained and have spent hundreds of hours in the field working with mental health agencies. Through their education and field experiences, they are thoroughly acquainted with ethical standards in social work practice particularly as these pertain to working with individuals who have serious mental illness. They have been instrumental in helping us revise our interview questions by giving us thoughtful feedback. This happy turn of events is more in keeping with the spirit of the Fulbright program, one of building relationships across cultures to foster collaboration and the mutual sharing of expertise.

The translation of effective treatments gleaned from clinical research into everyday practice is universally challenging for mental health professionals worldwide. Already, our Fulbright experience has enriched our understanding of the positive strides as well as the hurdles inherent in providing mental health services in India.

Teaching and Consulting

We’ve had lots of opportunities to share our expertise as teachers, researchers, and clinicians. At a two-day training program on February 15-16, we did two separate sessions on emotional and behavioral disorders in children and adolescents. We were featured speakers at the bi-annual meeting of doctoral students affiliated with Rajagiri College on February 9. During a recent accreditation team visit to Rajagiri, we had a chance to talk about our experiences as visiting international scholars.

Through our many interactions with faculty, students, and agency practitioners, we’ve had fascinating discussions about the struggles and the gratifying aspects of working with individuals and families as helping professionals.

Just in case followers of our blog have the false impression that this Fulbright-Nehru adventure  involved little more than combing tropical beaches, hiking in the Ghats, boating in the backwaters, and enjoying the company of local Keralans, here’s a list of our presentations and conferences to date – with more to come.

- Examining Subjective Distress from Trauma in People with Schizophrenia. Invited presentation, International Conference on Global Public Health and Social Work. Rajagiri College of Social Sciences, School of Social Work, Kerala, India. January 3.

- Employee Assistance Programming: Understanding Common Mental Health Disorders that Can Occur in the Workplace. Two invited papers presented at International Conference on Innovative Practices for Business Excellence. Rajagiri College of the Social Sciences, School of Business and Management, Kerala, India, January 14.

- Mental Health Interventions: An International Workshop on Case Management. Invited Presentation, Rajagiri College of the Social Sciences, January 19.

- Conducting Semi-Structured Key Informant Interviews with Mental Health Practitioners. Training session with second-year MSW students. Rajagiri College, School of Social Work, Kerala, India. February 5.

- Critical Reviews of the Literature and Research Design Challenges in Doctoral Dissertations. Invited presentation for bi-annual meeting of doctoral students, Rajagiri College of the Social Sciences, Kerala, India, February 9.

- Evidence-based Assessment and Intervention for Emotional and Behavioral Disorders Childhood and Adolescence. Featured presenters for training conference. Child Mental Health—Approaches and Strategies: An International Train-the-Trainers Program, Rajagiri College of the Social Sciences, School of Social Work, Kerala, India. February 15-16.

- Emerging Challenges in the Delivery of Mental Health Care. Presentation for South and Central Asia Fulbright Conference, Kochi, India, February 26.

- Best Practices for Effective Teaching on a South and Central Asian Campus. Invited participants for round table discussion. South and Central Asia Fulbright Conference, Kochi, India, February 26. 

- Implementing Evidence-based Practices in Community Mental Health. Invited  presentation. International Conference on Community Mental Health Services: Rajagiri College of Social Sciences, School of Social Work, Kerala, India (currently in preparation and scheduled for April).