Mental wellness takes centre stage

The picture card depicts two children, one of them eating an apple. "This is not kind. He is eating the apple without sharing it," says a child in Tamil. Another looks at a card that shows two people in conversation. "They are talking; this is kindness," the child says.

The children, from a Chennai school, are attending a session conducted by the Schizophrenia Research Foundation (SCARF India). The participants have been placed in three groups with three themes: gratitude, kindness and hope. Picture cards are distributed; and the children have to decide if the image on the card supports the group's theme. Some are shy, some speak in a rush, and some come up with imaginative stories. One by one, all the children have their say.

Character-building in children is a familiar concept. But when it is conveyed not just with educational tools but through art, theatre and storytelling, it can get elevated to what is called a positive psychological intervention (PPI). Whether this approach can have a positive effect on mental health is the hypothesis being tested in a randomised control trial (RCT) conducted by Chennai-based SCARF India in city schools. The experiment, which started in early October, will assess if the method of highlighting values through plays, art and storytelling is more effective than the pedagogical route.

The approach is connected with looking at mental health as a band ranging from flourishing mental health and wellness on one side to illness, diagnosis and rehabilitation on the other. The traditional approach has been to view mental health like other illnesses — identifying symptoms and treating disorders. PPI seeks to instil character strengths in everyone in a community — say, sections of a school — to develop the community as a holistic health unit.

Typically, psychiatric illnesses manifest themselves in early adulthood, sometimes even earlier. The illnesses are diagnosed. The general focus is on treating the condition, while PPI deals with wellness and well-being. PPI has taken off in the last two decades as a complementary strategy in mental health promotion and treatment (bit.ly/ppi-strategy). While this approach is common in the West, studies in the Asian and Indian contexts are few.

PPI is a paradigm shift in the approach usually followed by mental health professionals, says Dr M. Suresh Kumar, a psychiatrist and one of the lead researchers in the project. The usual way — focusing on early identification of established mental disorders, treatment and rehabilitating individuals — is burdensome, for there is a shortage of mental health professionals in India. According to a 2019 estimate, India has 0.75 psychiatrists per 100,000 people, while the desirable number is three or more per 100,000 (bit.ly/india-psychiatry).

"This is a deep focus on only one side of the continuum that is mental health. On the other side is enhancing well-being, and a flourishing of good health," he says. He points out that when the national mental health policy was framed in the 1980s, there was a focus on community wellness. "So, though the idea is old, there is a stronger focus on wellness now."

What is significant is that the approach applies to everyone, says Suresh Kumar, who is also the global head of the research and development wing of citiesRISE, a New York-based global platform promoting mental well-being among youth. The Chennai project, a collaborative effort between citiesRISE and SCARF India, is funded by the Templeton World Charity.

The children assessing the picture cards have been attending one such session, conducted by facilitator-psychologists Nithyashri Hariharan and Sreenithy Manoharan of SCARF India. Chatter fills the room, and Nithyashri shouts, "Kung fu". The children respond by yelling in one voice, "Panda". The group is thus called to order, and all at once, the psychologist has the attention of the 35-odd students from various classes.

After about ten minutes of songs and laughter, the picture cards are distributed. A brief discussion follows on why a particular picture is perceived as showing a specific trait. The children chip in one by one with their thoughts; sometimes with incidents from their lives. Then a discussion, and a song or two, and they are allowed to disperse, which they do noisily.

"It is a programme driven by young people; even the facilitators are in the 18-25 age group," says the research coordinator of the project, Dr Pavithra Arunachaleeswaran, a psychiatrist with SCARF India. While other programmes in SCARF focus on areas such as emotional stability and social adaptability, the RCT seeks to study the effect of inculcation of character strengths when delivered by art- and theatre-based interventions. An arm of this research also extends to Nairobi in Kenya, where a parallel branch of the same study is being carried out, with local social references. 

The RCT involves a group of 12 schools and 12 community centres, of which six in each category serve as controls. The art- and theatre-based interventions are provided in six schools and six community centres, and the remaining schools and community centres will teach the same concepts in a usual classroom-lesson form. The interventions will be given in eight weekly sessions, and the outcomes in the two different systems will be compared. This will test the hypothesis that art- and theatre-based interventions are effective in building up the three character strengths which, in turn, will have a positive effect on the overall wellness index.

Multiple co-design workshops with the participation of mental health professionals and experts in character strengths and in the arts were held to train the facilitators, who were also guided by artistes from Evam, a city theatre group.

The stories narrated at the sessions were simple tales, such as an adaptation of Aesop's fable about the tortoise and the hare. "We had to make it dramatic, use the props around the place, involve the children and generally make it engaging," Sreenithy says. "And that is where the training in arts came in." At the end of the session, the children are encouraged to discuss their experience. "This is the most important part, where they reflect," Pavithra explains.

The facilitators collect data by asking the children to answer a questionnaire about their well-being, social adjustments, environment and mental health. Their replies are gauged using the Warwick-Edinburgh Mental Well-being Scale, which is the standard for evaluating such interventions. The questionnaires are adapted to local social norms, as are the art forms, and will assess the impact of the programme on the participants.

There are enormous challenges in working with children and it has been a learning experience for both Nithyashri and Sreenithy. The sessions call for energy and patience, they stress. But the energy, the facilitators add, comes from the response of the children. The psychologists also feel that PPI is an effective strategy. "We could see signs of effectiveness in the pilot study itself," Nithyashri says.

A young boy reported how he had started helping his sister arrange her books, a task that he was earlier unwilling to do. Even in the sessions, the facilitators see positive change in the participants.

Nithyashri recalls, "Once, when a little scuffle started among the boys, another boy pacified them by asking them, 'Having taught us about hope, kindness and all that, isn't this exactly what they're telling us not to do?'."

Suresh Kumar adds that SCARF India has come up with a 'three plus one' framework. The 'three' refer to strengthening the inner self; social connectedness; and the environmental ecosystem and local socio-political climate. The plus one refers to system and policy — measures that relate to mental health, such as State governments developing a mental health curriculum for schools or schools appointing counsellors.

"We are convinced that if we focus on strengthening the inner self, the rest will follow," he says.