Tele-counsellor (TC): “I am calling on behalf of the Bihar govt, can I ask you a few questions about your health post your treatment for Covid in hospital?”
Policeman patient : “I used to feel constant fear earlier, I also had memory loss and got angry a lot, I am better now but I still get tense easily.”
TC: “I understand and I am here to help you. Think of the fact that you survived Corona, you are lucky to be alive, you fought and won, keep telling yourself that and slowly the negative thoughts will pass…”
Counsellor-mentor: “Are you R’s husband? May I talk to her about her health post Covid hospitalization?”
Reluctant husband: “You can talk to me, we both had Covid and spent ten days in a private hospital. We are alright now.”
A little later he allows his wife R to come on the line; she admits to feeling fearful, crying for no reason and getting tension headaches each time she remembers her Covid trauma.
Mentor: “Do you get angry for no reason or feel alone or sad at times?”
R: “Yes, sometimes I feel I will die, I don’t get enough sleep either.”
Mentor reassures R at length--asking her to throw out from her mind all the images of the disease, to eat well, to watch a comedy serial, to drink hot haldi-doodh (turmeric milk) at bed time—she will follow up with her in a week’s time.
R’s husband ends the call, willingly promising to connect them in future.
It is an enormous task that CARE and PCI (Project Concern International/India) have jointly undertaken along with the Bihar government since June 2021—a new initiative to reach out and reduce the mental health burden of recovered Covid patients. It’s called ‘Connect, Communicate and Console’ comprising a team of 30 counsellors, 9 coordinators and mentors, all trained by mental health experts at Nimhans, Bengaluru, India’s apex institution to oversee mental health (MH) initiatives.
First, track down recovered Covid patients from their hospital records, get trained tele-counsellors to call them, convince them to share their health details, identify problem areas, further coax them into revealing any past or lingering mental health (MH) issues, provide counselling advice and follow up as per time protocols. This psycho-social first aid to Covid-affected families also includes telephonic medical assistance for specific cases.
Since this is the first outreach of its kind in Bihar, the initial queries are more about financial aid or vaccine information and less about mental health issues but the counsellors use the Empathetic Inquiry Format.
Empathetic Inquiry: What Questions Get Asked?
Do you often feel sad or depressed?
Do you feel nervous?
Do you feel lonely?
Do you feel scared about anything?
Do you cry for no reason?
Do you often feel angry?
Do you have trouble sleeping?
Do you have a good appetite?
Do you have problem concentrating on work?
A point-system score card is recorded based on the answers, a second and third follow-up call after a week or ten days is done in case the scores are high; mentors and qualified psycho-therapists step in for the more serious cases. Cases are closed based on the closure checklist.
“Initially nobody would talk about any of their MH issues, there were less than ten percent who admitted to MH problems, even our graduate TCs would categorise them as ‘mental’ instead of MH, the stigma is so ingrained and remains the biggest challenge we face in our project,”Rajshree Das, Programme Head, PCI
Once the tool Empathetic Inquiry with 9 parameters to screen MH issues was introduced, the percentage rose to 19, with female MH patients being more common as also those who were hospitalised for Covid or had a Covid-related death in the family.
The team reached out to 13,963 patients in the three months since the project began, supporting 8758 persons, an impressive 63 percent in an urban-rural mixed sample size. Rural Bihar respondents were more reluctant to voice MH concerns even though the state’s migrant labour male population translates into loneliness and related symptoms even in a non-Covid scenario.
The pandemic of course threw unexpected curveballs in terms of both physical and mental health crises, for a world and population unprepared and ill-equipped to cope with it.
“In any disaster—tsunami, earthquake, floods, riots and now Covid-19—the invisible impact in terms of mental trauma often exceeds the physical yet it remains unaddressed, often for years. Psycho-social care is thus an integral part of disaster management; an on-going, flexible aspect with no time limits set on ‘normalisation’. In a pandemic with its obvious restrictions, tele-counselling, talking, group activity is the preferred modus operandi with medical intervention and treatment needed for only a small percentage (less than 5) of stressed survivors,” says N M Prusty, mental health expert and advisor to the project.
The approach is both different and multi-pronged—a technical service, a MH service, a mentor network project design. Each call—lasting around ten minutes, with mentor calls of longer duration-- is recorded, TCs are supervised by counsellors and told to call again in case of any lacunae. They average 10-12 patients a day. Screening to closure Standard Operating Procedures or SOPs include follow up calls after intervals of two, four, seven and ten days—a time-frame that is perhaps unrealistic for anyone needing psycho-support for a sustained period.
Call duration limits are also clearly insufficient to address the vast labyrinth that has to be negotiated before a person even admits to feeling sad or angry or lonely.
Tele-counsellors need regular inputs by therapists and MH professionals to update their skillsets in dealing with and helping patients, all of whom are faceless voices at the other end of the telephone.
Confessing your innermost fears and anxieties is difficult in the most ideal conditions, admitting them to a stranger on a mobile call is a herculean task, as is that of listening and providing instant solutions, in a one-size-fits-all scenario.
The advice offered by the tele-counsellors is therefore fairly generic—exercise regularly, eat well and often, reduce oil and spices in your food, stay away from negative thoughts and toxic people, don’t try to control your emotions, cry if you feel like it, listen to music or distract yourself watching a comedy serial, do breathing exercises and meditate, don’t dwell on your Covid trauma because you fought and survived it, you are a winner and we are there for you, we will call you again.
This feeling of someone having your back and concerned about your health—mental and physical—is a sustaining belief for most people on the receiving end of the tele-counselling initiative, they have been heard, their problems discussed and they count. For a populace battling various forms (and levels of severity) of mental strain and trauma—anticipatory anxiety or fear of Covid-19 infection, grief over losses of loved ones, loss of livelihoods, hopelessness about an uncertain future—to be heard and consoled, matters considerably.
“Helplines reach out to those who call in, we proactively seek out recovered Covid patients from hospital records and provide psycho-social first aid. If MH evaluation is made mandatory for all Covid patients on their release from hospital, that would ensure a wider reach. The same model could be implemented for our new Mother and Child Health (MCH) tele-counselling program. ASHAs (Accredited Social Health Activist) and anganwadi workers could be a huge asset in such programs given their expertise in community health care. There is an urgent need to scale this Bihar model in other states as well and to create awareness on ground about MH in order to remove the stigma and make the service accessible,” explains Rajshree Das earnestly.
And that task--of destigmatizing mental illness and mental health patients--is perhaps as great a challenge as handling anything a pandemic can throw up at the worst of times!
(Minnie Vaid wears many hats—a journalist, documentary film maker, television professional and author. She is passionate about fighting against injustice via her films and books, is happiest while shooting with villagers in rural India and loves Shahrukh Khan–perhaps in precisely that order!)