BasicNeeds: Helping the Mentally Ill Live Productively

As a young man, Chris Underhill,MBE, worked in Zambia withVoluntary Service Overseas(VSO), the British version of the PeaceCorps. On a trip to nearby Malawi, hesaw "mentally ill people behind barsbeing goaded by a group of people whofound it funny." He was deeply affectedby what he witnessed.

"I have always felt that people whoare ill, maimed . . . need to be supportedin a nonsentimental way and in a waythat gives them some kind of aid(economic and functional aid), whichwould obviously help them make theirway in life," he said in an interviewwith Psychiatric Times.

Acting on his beliefs, Underhill hasfounded several charitable organizations,the most recent one being "BasicNeeds",a program in developing countries thatworks with individuals with mental illnessor epilepsy, their families, and theircommunities to establish accessibletreatment programs, satisfy basic needs,and reduce social marginalization andstigma.

Before creating BasicNeeds, Underhillhad founded "Thrive" (formerly"Horticultural Therapy"), which usesgardening to change the lives of disabledpeople in the United Kingdom, andAction on Disability and Development,which works with physically disabledpersons in Third World countries.

"While I was working in the fieldof disability, I kept an eye out for whatwas happening to mentally ill people,and realized that there was nothingmuch going on in developing countries.I had a growing conviction that I shoulddo something about it," he said.

He did so in 1999 by registeringBasicNeeds as a charitable organization.The funds to start BasicNeedswere contributed by Andrews CharitableTrust (née World in Need) and the JoelJoffe Charitable Trust. These donationsmade it possible for the organization todevelop its overall policy and strategy,for a sister trust to be registered in India,and for most of the pilot work to bedone from 1999 to September 2000.

Currently, with an international staffof 51, BasicNeeds is working in India,Sri Lanka, Ghana, Uganda, Kenya, andTanzania and is establishing a programin Lao PDR (Laos). From the start ofits operations in September 2000through December 2005, Underhillsaid, the organization has managed apatient/client volume of 28,411 persons, about 60% of whom have a mental illnessand 40% of whom have epilepsy.The organization also helps their estimated142,000 family members.

Financial support for the ongoingwork of BasicNeeds comes from theBritish government's Department forInternational Development, the Britishequivalent of the United States Agencyfor International Development; ComicRelief, a UK charity that funds developmentalprojects primarily in the poorestcountries of the world; a range oftrusts and foundations; and some philanthropicangels.

Goals

BasicNeeds' goals include arrangingfor satisfactory and effective community-based care—including treatment,support, and addressing the issues ofpoverty and stigma—for persons withepilepsy or with schizophrenia, depression,bipolar disorder, or other debilitatingmental disorders. Achievingthose goals is a challenge because ofthe scarcity of trained mental healthprofessionals, particularly psychiatrists,and the lack of community-basedfacilities, Underhill said. In Tanzania,for instance, there are 14 psychiatristsfor some 37.7 million persons, and inMalawi, there is one locally born psychiatristfor 12.3 million persons.

Community-care facilities have yetto be developed in nearly half of thecountries in Africa and South Asia whereBasicNeeds works. Consequently, mentalhealth care in many countries involvesplacing individuals in institutions, wherein some instances they are physicallychained and abused, according to informationon BasicNeeds' Web site.¹

Several countries in Africa have just1 hospital for the mentally ill, Underhillreported. Apart from the treatment concernsof persons with mental illnessstaying in institutions for many years,he explained, it is almost impossiblefor families to transport the person withmental illness to the hospital if it islocated a significant distance away. Ifa traumatic event occurs and the familydecides to take the person with mentalillness to the hospital, they may haveto calm him or her with a tranquilizer,tie him up, and take him by bus, frequentlyin 40°C (104°F) heat.

"So you have a human rights problemright there," Underhill said. Thereare human rights violations in thecommunity as well, he added. Becausemost families do not understand whatis wrong with the family members who are mentally ill or epileptic, they maychain or tie them up and beat them.

Community mental health model

Valuing human rights, promoting inclusion,obtaining psychiatric treatmentin the community, and creating partnershipswith government departmentsand community groups are all part ofBasicNeeds' comprehensive approach—an approach that is regarded by manyas both innovative and sustainable.

For example, in a project visit reportto the UK's Department for InternationalDevelopment, Triple LineConsulting Ltd, which assessed thework of BasicNeeds and 3 other organizationsworking in Sri Lanka orIndia, said "BasicNeeds' project in SriLanka, which combined a medicalmodel of mental health treatment withcommunity development approaches,was the most innovative of the 4 projectsreviewed." The report also notedthat the changes that BasicNeeds hasfostered in the country "show good potential for sustainability."²

BasicNeeds avoids the traditionalmodel in which charities or church-basedbodies look after persons with mentalillness. Instead, it uses a communitymental health and development model,which Underhill said enables the organization"to reach out and touch so manypeople in a meaningful way." Underhilldevised the model, and between Januaryand September 2000, D. M. Naidu, adisability activist for some 25 years,field-tested it in southern India.

The model has 5 interlinking components:capacity building, communitymental health, sustainablelivelihoods, research, and managementand administration.

Capacity building

Capacity building, Underhill explained,involves contacting persons in a community,particularly those who arementally ill and those with epilepsy,as well as their caregivers, families, friends, and representatives of communitygroups. They are invited to communitymeetings conducted in a room at adistrict hospital, in a schoolyard, or evenoutside under a grove of trees. Participantsusually divide into 3 groups: persons withmental illness or epilepsy, the caregivers,and persons working with local healthfacilities and community organizations.

"We bring people together and askthem simple questions: What is yourworld? (In other words, what is happeningto you and around you?) What areyour needs? How do you want to goforward?" Underhill said.

In that process, those with mentalillness or epilepsy are given, often forthe first time, a voice in how they wantto be treated and how they want theirtreatment to proceed. They demonstrateto themselves, to their caregivers, andto community representatives that theyare capable of lucidly discussing theirlives and concerns.

"They know the results they are lookingfor. . . . They want treatment, whichthey hope will reduce the symptoms theyare experiencing and give them a morenormal life, and they want to makecontributions to the family income. Inthe case of heads of family, they wantto go out and earn an income like theyused to," Underhill said. "When you aresitting in the room and quietly watchingand the mentally ill people stand ina group [often comprising 60 or morepeople] and start to go through theissues they have put down on their flipchart,a silence spreads across the room.That moment is extraordinary, becauseit is the first major chip away at stigmathat exists between [caregivers] andmentally ill people." To clarify, heexplained that up until that moment,caregivers often considered individualswith mental illness solely as a burden,an attitude frequently shared by othersin the community.

At the meeting, all 3 groups discusswith BasicNeeds how to arrange formedical and psychiatric treatment, howto form ongoing groups, and what needsto be done. Central to this part of themodel is the creation of communitylevelvoluntary committees that includepersons whose mental illnesses is stabilized,caregivers, and community volunteers.Partnerships are created withwomen's groups, rehabilitation organizations,and other associations.

Community mental health

The second component of the model iscommunity mental health. BasicNeedsdoes not give direct treatment. Rather,it usually works with the country's ministryof health to create mechanisms bywhich persons with mental illness or epilepsy can easily access services.Typically, the government provides apsychiatrist, psychiatric nurse, or othermental health professional. A group inthe community hosts the specialists.

At a designated location in a community,the psychiatrist begins seeing andassessing patients, many of whom havesuffered from mental illness for up to25 years with no diagnosis and no understandingof why they feel as they do.

Training workshops for partner staff,health service providers, governmentofficials, medical practitioners, communityleaders, and elected leaders of localgovernments are also provided.

Underhill explained that the trainingprocess can be likened to a pyramid-sellingtechnique. "Instead of selling makeup,we sell the idea of how to treat mentallyill people." A psychiatrist may train localdoctors on how to diagnose and treatmental illness. A small number of psychiatricnurses are taught how to train othersto care for those with epilepsy or mentalillness. The psychiatric nurses, in turn,train the general health staff in communities,such as nurses or assistant nurses.

In Dar es Salaam, a port and capitalcity of Tanzania, Underhill said the pyramid-training process was used to train150 general health staff members in 3areas of the city. Before the BasicNeedsmodel was implemented, 3 to 15 mentallyill persons would turn up monthly at localdispensaries, with many of them being misdiagnosed or referred for treatmentto facilities many miles away. Now, atthe same local dispensary, 30 to 45 personsare being appropriately treated eachmonth.

The medications provided, Underhillnoted, are usually generic versions ofpsychotropics that are less expensive butmay be prone to causing more side effects.In some countries, the medications arefree but limited; in others, the governmentsubsidizes a portion of the cost, whilethe remainder must be paid by the patientsand their families.

Because they often need to purchasetheir own medications and becausethey need to contribute to the financialsupport of their families (the averagefamily income in the groups with whichBasicNeeds works tends to be aboutUS

50 per year), individuals withmental illness or epilepsy receive guidancefrom BasicNeeds and communityorganizations in earning a living.

Sustainable livelihoods

The third component of the model issustainable livelihoods.

"Livelihood is where people are earningmoney or where they are makinga contribution by doing somethingin their family," said Underhill. "About64% of our current 28,400 patients/clients are earning or contributing; 22%are earning an income and 42% are engagedin productive work or have goneback to school. An example of productive work is when they help with thefamily farm plot."

That is something patients can beproud of, he added, and it would nothave happened without the assistanceof the voluntary community organizationsand other partners.

For some individuals with mentalillness or epilepsy, small-scale horticulturalprojects enable them to growand harvest vegetables for their families. Others, with the help of communitygroups, are involved in micro-enterprises, such as brick making, goatrearing, and candle and incense stickmaking.

Research

The fourth component of the model,research, focuses on encouraging personswith mental illness or epilepsy to articulatetheir perceptions about their situationand needs and create their lifestories, which may later be publishedwith their permission in Mental Healthand Development, the e-journal producedby BasicNeeds.

In addition, files are created on eachperson, documenting his or her diagnosis,medications taken, and progress,particularly with regard to income generationor contributions to the family.Those data are aggregated, enablingBasicNeeds' policy and research team,based in India and Sri Lanka but workingworldwide, to produce consolidatedreview reports from country programsevery 6 months.

Management and administration

The fifth component of the model,management and administration, involveswork with the government departmentsin each country and withcommunity-based partners (generallynot-for-profit organizations).

It is important to have the governmenton board, so that the organizationknows it is welcome in the country, saidUnderhill. Government departments arealso usually the main players when itcomes to the delivery of mental healthcare and providing resources, so theorganization needs to partner with them,especially since it is the governmentagencies that often provide the psychiatricinterventions.

BasicNeeds also provides training toits community-based partners in projectmanagement, including "logframes"(logical framework tools for project design),budgeting and finance, monitoringand evaluation, and reporting.

Role for US Psychiatrists

Asked how US psychiatrists might assistBasicNeeds, Underhill said the organizationis contemplating starting aworldwide fund so that more psychiatristsand psychiatric nurses from developingcountries in Africa and Asia canreceive training. US psychiatrists couldhelp with that project.

"Second, it would be possible, perhapson a volunteer basis, for competent andvery experienced psychiatric staff to offertheir services to help us run some ofthe shorter training courses, especiallythose related to diagnosis," he said.

US psychiatrists and other mentalhealth professionals attending the 19thannual U.S. Psychiatric & Mental HealthCongress, November 16 to 19, 2006, inNew Orleans, will have an opportunityto learn more about the organization;Underhill is scheduled to be 1 of the presenters,and the organization plans to havea booth in the exhibit hall.

In assessing his life's work, Underhillemphasized the satisfaction he felt inseeing his organization reach and helpthose in need and serve as a model forothers to emulate.

The organization's success can be demonstratedby the impact it made on onelife. Juma Ali Livinda, a young man withmental illness, was brought in with chainsand shackles on his hands and legs to acommunity meeting in Tanzania arrangedby BasicNeeds. Nine months later, becauseof total care he received at a nearbyhealth clinic, including the provision ofpsychotherapeutic drugs, he was no longerchained and shackled and was workingproductively on a cashew farm.³

References:

References1. BasicNeeds. The problem. Available at: http://www.basicneeds.org.uk/problem.html. Accessed April 5, 2006.
2. Giles C, Triple Line Consulting Ltd. Civil SocietyChallenge Fund-Project Visit Report-India and SriLanka. Prepared for the Department for InternationalDevelopment. Available at: http://www.dfid.gov.uk/funding/indiasrilanka-visitreport.pdf. Accessed April5, 2006.
3. BasicNeeds Review. Community, My Community.Available at: http://www.basicneeds.org.uk/bnrevw03.pdf. Accessed April 5, 2006.