Abstract

The mental health discourse in India has been primarily viewed through a biomedical lens that often overlooks the cultural context and social inequalities. To ensure equitable access to preventive, promotive, curative, and rehabilitative mental healthcare, India needs practitioners who combine a social perspective with an empathetic approach. To address this need, we designed a course titled “Critical Perspectives on Mental Health” that aims to introduce the relevant perspectives and community-based approaches to mental health. In this article, we share our reflections on designing this course and facilitating it in the form of a post-graduation programme.

Keywords: mental health, public health, teaching reflections, pedagogy, inclusive learning

Introduction

Despite the broad definition of health as “a state of complete physical, mental and social wellbeing and not merely an absence of disease or infirmity”, the mainstream public health discourses have largely ignored the mental health-related needs and experiences of diverse communities in the world [1]. While the pandemic attracted our attention to mental health issues, the focus primarily remained limited to individual counselling, coping, and the “illness” narrative [2, 3]. The narrative around mental health has also largely remained restricted to mental healthcare, thus falling short of situating itself in the broader public health domain [4]. There is a felt need to address the social determinants of mental health, to consider mental wellbeing as a spectrum, and to promote socially oriented actions to ensure “mental health for all”. The Lancet Commission on Global Mental Health and Sustainable Development argues that mental health is a global public good. The WHO [World Health Organization] Special Initiative for Mental Health [2019-2023] promotes universal coverage of mental health and the United Nations Human Rights Council (2022) emphasises the protection of rights to the highest standard of physical and mental health of diverse populations [5, 6, 7]. These are welcome additions to the global narrative on mental health. However, to achieve these, there is a dire need for a public health approach [rather than a narrow biomedical approach] to ensure equitable access to a mental healthcare that is preventive, promotive, curative, and rehabilitative. As the biomedical lens has historically ignored the complex role of the various sociocultural, political, environmental, and economic structures in creating and sustaining mental health inequalities, it is necessary to discuss, acknowledge and address these social inequalities in Indian society. Given the stigma around mental health, sustained efforts are required to work with communities to understand how they express mental well-being, their experience of ill health, their ideas of normality, and their views on seeking mental healthcare. Public health practitioners with these perspectives and empathetic attitudes are urgently needed in India.

Designing a course on mental health

Several academic courses on mental health remain tied to the boundaries of psychology and psychiatry, leaving no opportunities for budding practitioners to develop public health perspectives that are crucial for designing community-based approaches to tackle the “silent” mental health epidemic in India [8]. A group of faculty members of the School of Development at Azim Premji University with diverse academic backgrounds strongly felt the need to design a course on mental health that addresses this gap in academia. The course design team consisted of faculty members trained in medical anthropology, public health, and economics with health systems management, respectively. All three have long experience of working with marginalised and vulnerable communities, while two of them are experienced in designing pedagogies in public health and mental health.

The course was designed in May 2022 and was approved by two academic review committees namely — the institutional course review committee and the curriculum and pedagogy committee. Both the authors, who were members of the course design team, offered this course to the second-year students of the Master of Arts (MA) Development programme at Azim Premji University in 2022.

In this article, we reflect on what it has meant for us to design and teach a course titled, “Critical Perspectives on Mental Health” offered as part of a Master of Arts in Development programme that aimed to facilitate learning focused on a public health perspective on mental health. This course aimed to encourage students to a) appreciate the public health perspective as contrasted with a bio-medicalised and individualist orientation on mental health and wellbeing; b) understand what such a perspective entails and how it matters for sustainable development; and c) learn from existing community-based mental health interventions to promote mental health and wellbeing. The course aimed to cultivate an ethical and empathetic perspective on the common mental health challenges. Second-year MA Development students opting for this elective course would be expected to draw on their learnings from courses such as the “Sociology of Modern India”, “Theories and Histories of Development” and “Social Interventions”. Their learnings from these mandatory courses in their previous semesters were expected to help them appreciate the discussions on the perspectives and interventions on mental health.

The MA in Development programme students come with diverse socioeconomic profiles, geographical locations, life experiences, and histories. For instance, in 2024, the postgraduate programmes at the university have students from 25 states, more than 44% students come from small towns and rural regions, and about 60% are women. Students bring diversity in academic and work experience to the programme, as around 22% students have more than two years prior work experience at non-governmental organisations, in teaching, or at corporates [9]. Our classes are microcosms of such diversity. This diversity is reflected in the heterogeneity of their experiences and responses to various stressors and in the inequities in their ability to seek support. Therefore, as this course tried shaping the perspectives on mental health from “individual” to “population” and from “illness” to “health”, we reflect on our experiences of teaching a class of 30 students in this 15-week-long course.

Learnings from the course

We had clarified to the students, from the outset, that the course was not a therapeutic class and that none of the instructors was a trained counsellor. However, we realised through this journey that there was no easy and strict boundary. The more we invested time in discussing and deconstructing mental health, including stigma, the social construction, and determinants contributing to mental health; the more we observed that it was, in some sense, therapeutic in a non-deliberate way as a few students were comfortable about sharing their personal experiences. One student shared how he felt lighter after the discussion on de-individualising the burden of mental health challenges, as he had been blaming himself for the challenges he faced. As students would share their personal stories with us, we realised that they were looking for active listening in a non-judgemental space.

Throughout the course, we kept reflecting on our own positionalities as facilitators. We were aware that while an active learning space could facilitate sharing among classmates and help them make sense of their own observations and experiences, it could be a traumatic process for some as they shared their own or their loved one’s diagnosed “pathologies”. While seeking to create a safe space for students to help them appreciate a variety of concepts such as “intergenerational trauma” (where group trauma such as racism can have a cumulative mental health impact across generations), we wanted to be sensitive about the language used in the classroom, and the context-specific examples we brought out as there was a possibility of these experiences directly resonating with someone’s memories. A few students connected their mental health-related struggles with societal pressure — eg for belonging to a sexual minority, or their family’s struggles of belonging to a religious minority — as we discussed marginalisation and mental health, and intergenerational trauma.

We deliberated on the pedagogical approaches and tools for each class to help deconstruct concepts such as “stigma”, “intergenerational trauma” and “marginalisation” and their nuanced connections with mental health that often seem quite abstract. For example, our first class was dedicated to creating their definitions of mental health, followed by a class discussion to define it comprehensively. This exercise helped broaden their boundaries to define mental health as “cognitive, behavioural well-being”, “medical history”, “state of mind” or mere absence of mental illness to appreciate even the social wellbeing-related aspects of mental health. We used case stories developed by the People’s Archive of Rural India (PARI) to lead group discussions on the factors, actors, and processes through which social, political, and environmental determinants affect mental well-being [10] .

The discussion on the social construction of mental health and stigma was unpacked by encouraging students to work in groups to draw visual images and describe common words in English/regional languages used for people with mental health conditions. Students shared vivid memories and experiences as they drew visual images of people with psychosocial disabilities in groups. Students shared their memories of hearing the words “mental” “paagal [Hindi]” “Veda [Marathi]” “gone case” “idiot” “tale kettide [Kannada]” in their respective regional languages as referring to people with psychosocial disabilities. Several students reflected on how they equated mental illness with violent and aggressive behaviour without realising that they were inadvertently contributing to the stereotyping and stigmatising norms.

Students also celebrated World Mental Health Day by extending the discussions on mental health beyond the four walls of the classroom. The idea of a safe space was experienced through activities that highlighted the importance of looking within, as much as the concept of social connectedness. One student testimonial read-

On the 10th of October, we truly celebrated World Mental Health Day with so much vigor and enthusiasm. The best part of the session was with minimal words we all were able to communicate and learn about mental health. The magic of nonverbal communication and the aura the music created is something that I will cherish and will always remember to celebrate mental health…

The students graduating from the MA Development programme are generally expected to work in the social sector. Hence, we invited practitioners who work in the domain of mental health to help them apply their public health orientation to potential community-based mental health interventions. As an extension of this exercise, students were asked to present the learnings from five community mental health interventions that helped liberate the individual and illness approach to a comprehensive public health approach. One student said-

When we talk about mental health, many things come to mind at the same time, such as mental health hospitals, institutional health care, and social stigma. This course helped shape [my] community knowledge to cure the people and come out of the mental stigma I had in my mind.

In a workshop-like set-up for one class, students were encouraged to design a mental health intervention for the fellow student community around them. Students carefully chose a community approach rather than a clinical approach as they deliberated the ideas of informal meetings, sharing, and creating a safe space for themselves. It culminated in demonstrating their understanding of mental health and their agency in creating a safe space among peers. This was reflected in one student from this course proactively engaging with his peers in “origami-talks” where he voluntarily spent time with his peers discussing their journeys, challenges, and dreams while co-creating origami art pieces trying out one possible art-based intervention to discuss mental wellbeing. Consciously choosing these pedagogical approaches ensured that students remained actively engaged in discussions that could be cathartic or traumatic. One student shared this:

The inclusive learning and group work helped me better understand how it can be applied. The course interests me because it gives a community health aspect rather than understanding different illnesses. The workshop where we had to develop a programme was very insightful.

We designed assessments for students that aim to evaluate students’ ability to explain how various factors shape mental health, their ethical sensibilities to understand the mental health challenges faced by marginalised communities, and their ability to learn from community mental health interventions [supplementary file: Course document].

Although several students found the course helpful, we received feedback on the need to include a more detailed discussion on the inter-relationship between physical and mental health. Students also suggested inviting more practitioners to learn the approaches and challenges in implementing community mental health interventions. A student suggested that we include the contribution of Arabic scholars such as Al-Razi and Al-Balkhi in documenting the description of mental health conditions during the golden era [roughly from the 8th century to 16th century]. This helped us to reflect on our choice/s regarding course content and to discuss it in the next class.

Based on these learnings and reflections, we think that this course can provide students who are future development practitioners with a public health lens to address mental health issues. It will develop new ideas and avenues for addressing the mental health needs and concerns of marginalised populations in India whose voices remain unheard. This course also underlines the need to be reflective about our own positionalities as facilitators, being empathetic listeners, carefully choosing pedagogical resources, and being mindful of students’ vulnerabilities while seeking to create a non-judgmental space in the classroom to discuss this sensitive topic.

Acknowledgement: The authors thank Prof Arima Mishra for her insightful feedback throughout the course, as well as on the drafts of this article.