A small project I work with here in India is about “community mental health competence”. Community what? Exactly- its something nobody understands. Not even them.
People with Psycho-Social Disability (PPSD) are poorly treated and excluded all over the world. In rich countries despite psychiatrists and psychiatric nurses (often from poor countries), counselling services, alternative therapies and myriad other resources mental health is a burgeoning problem. How then can poor communities in under-resourced countries accept PPSD, include them in community life and contribute to their wellness. Attempting to contribute to that in Indian communities is like using your toes to untie a knot with no ends- you’ve no idea where to start and no resources for the problem at hand- er foot.
But they did start, this little team. After three years well trained community workers visit over a thousand patients and care givers in their homes, making care plans, bringing patients to the counselling centre they started in a. church, getting people to the only psychiatric facility nearby, involving community leaders, coercing an unwilling government to agree to supply medications, trying income generation projects for carers, supporting resiliency in young people and more… But they also advocate for medications, train doctors, input to policy, present at conferences, research their issue, include community nurses….. They even presented to the national government in Delhi recently. Outstanding!
Here are some lessons about working in complexity I’ve learned from them:
1. Focus on the behaviour of people and institutions- what they do, how they think, how they relate and the rules they make for themselves (aka policy). This project uses Outcome Mapping, but the specific tool is less important than the thinking. The way into complexity for development projects must be via people and groups of people. Messy and very messy- but that’s complexity.
2. Systemic thinking. This project not only engages with PPSD in their context but also asks what the system those people are nested in is about, who relates to whom, what their perspectives are and what is relevant in each space. They look for ways into the issue everywhere from a mud floored plastic bag roofed slum house to a government ministry in Delhi. They conceptually connect multiple levels of the system in their thinking then deliberately engage in those spaces. Inspiring.
3. Flat management. I am always impressed by this team’s relationships. Views and opinions from any and every member of the team are encouraged. In situations where answers are not known anyone is as likely to have relevant insights. Top-down management which is good for implementing protocolled answers, n complexity throttles relevant answers before they have a chance to emerge. Even “Sir” and “Ma’m” which seem respectful, innocuous at most, suggest lack of freedom to agree, disagree, suggest, innovate, experiment, look stupid. This team shares lunch, dances sometimes, and laughs together often.
4. High level conceptual thinking, wide networking. The project director, one of the planet’s few people with a PhD in community mental health, reads, writes thinks and talks about her subject continuously. Other team members also research, write, attend conferences…. think. So a team open to ideas grounded in the real-world from grass-roots (via flat management and engagement with people) also grapples at conceptual and theoretical levels and networks with others working with similar issues in different contexts or with similar approaches to different problems. Last week I facilitated a reflection morning with two other projects- one from 40 km away and the other from Cambodia- which also use Outcome Mapping. Yet again the project was deliberately connecting with ideas-and people.
5. Experimental and iterative. Some of the energy I feel when I work with this team derives from their experimental, iterative approach. As well as getting patients to medications and psychiatrists they also started a community counselling centre, youth resiliency groups, tried income generation, are looking at parenting, engage politically, run corner groups to give information, print simple pamphlets in Hindi…. they even tried chicken raising. Poultry as an answer to mental health???? Wild! They’re currently considering sports in a bustee(slum) as an engagement strategy for substance abusers and women. It might not “work” but they’ll try anyway and learn something. They follow their noses and take risks and nimbly move to a different space if something is not successful. Exploring by doing. Throwing multiple small probes out there knowing some will not work…. Great for complexity.
6. Reflection. Exploring by doing is pointless without putting time into understanding what happens. I was with the team recently facilitating discussion on what had, and had not, worked with chicken raising and other income generation ideas. In fact there was much to learn about what happened, what people did, said and felt about it. This team is continuously gathering lessons from their probes via outcome focused monitoring, reflection meetings, people’s stories.
7. Engage at multiple levels. Complexity Implies multiple causes and myriad effects without straight line one-to-one connections. Engaging with only one dimension of a problem almost certainly will achieve little. In this case the relative importance of medications, information inclusion, policy, economic security, government policy, discrimination, lack of education and myriad other possible “causes”, the relationships between them and how they play out together is unclear. This project approaches its problem in many different ways, often using many strategies together (e.g. medications, counselling and income generation strategy for a PPSD and his care giver or advocacy, scientific information and an offer to collaborate on a paper with a government officer). Deliberately engaging at many levels is mandatory for complexity. This project does it superbly.
8. Similarly I like the way this team works in different geographic and social spaces of their issue. Their implementing partners work in different cities, in semi-rural and urban locations, sometimes specifically with youth, women care givers, substance abusers, economically disadvantaged etc. Only by doing that can they unravel which of their lessons are about human beings and mental health and which are about a specific social or geographic space.
This exploratory project prioritises quality over size, people over numbers, experiments, exploration, reflection, dreams. I choose complexity so have have worked with many projects with some elements of good complexity design but none that combine so many. I’d call this a model project…..except that for complexity I don’t believe in models .