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World Mental Health Day, 10 October: Mental health in an unequal world 

09 Oct 2021

  • Can we balance the scales? 
On 10 October 1992, the World Federation for Mental Health, led by then Deputy Secretary General Richard Hunter, celebrated the first World Mental Health Day. This year, the theme of “mental health in an unequal world” was chosen in light of how increasingly polarising the world has become, with many segments of the population falling below the poverty line and the wealthy becoming wealthier. 2020 and the pandemic exposed inequalities stemming from racial, ethnic, sexual orientation, and gender identity-based discriminations, along with human rights violations across many countries in the world.  Sri Lanka still struggles with a perceived taboo that surrounds mental health, and our availability and allocation of resources have a long way to go in becoming equal. To understand these disparities better, Brunch spoke to Sri Lanka Psychological Association (SLPA) President Clinical Psychologist Dr. Kanthi Hettigoda (PhD) and Edhati Consultancy Founder Management Psychologist Iranjali Unamboowe Abeyratne. Scarcity of resources, unequal distribution, and inadequate recognition  [caption id="attachment_166482" align="alignright" width="316"] SLPA President Clinical Psychologist Dr. Kanthi Hettigoda (PhD)[/caption] Discussing World Mental Health Day 2021’s theme in the Sri Lankan context, Dr. Hettigoda stated that our biggest challenge is a lack of resources and its unequal distribution, adding that while there are psychiatrists in almost all base/teaching hospitals, not every individual is able to reach out to these services. “If we consider the government sector and mental health professionals, we have an abundance of psychiatrists, but only around 200-odd counsellors in social services, and just 60-odd in the Child and Women Bureau. We have no psychologists in the government sector at present,” she said. Dr. Hettigoda also raised concerns about the fact that there is a severe lack of mental health professionals in the northeastern parts of the island, which she attributed to a lack of initiative on the part of the government to recruit psychologists within the government sector. Dr. Hettigoda shared that those who are recruited are limited to the main areas of the island such as Colombo, Kandy, or Kurunegala.  “The lack of recognition for psychology in Sri Lanka as a profession is leading to many qualified individuals migrating elsewhere,” Dr. Hettigoda stated. Discussing barriers in accessing mental health services, she added that psychologists who practice privately need to charge at least Rs. 2,500 per session, which greatly limits the segment of the population that can access them, which is also why the numbers of government sector psychologists must increase. However, she also added that budgetary allocations may be a challenge for the government to fulfill this requirement.  A system in reverse, and deep-seated stigmas The SLPA President stressed that encouraging people to access whatever resources are available to them is imperative to fostering better mental health: “The majority of the general public do not reach out for mental health assistance. The World Health Organisation (WHO) has stated that while the pandemic may dissipate in a few years, the psychological impact of it may linger for much longer, and I have my doubts as to whether Sri Lanka can handle this oncoming challenge.” The pandemic has further exacerbated this issue, in Dr. Hettigoda’s opinion, by limiting how much people can travel around to access services.  Misconceptions around mental health also contribute to stigma and lack of awareness, with Dr. Hettigoda noting that most people outside of Colombo (and even within Colombo in some cases), are unaware that medications are not always necessary in psychological treatments. “Most people believe they need to only meet a psychiatrist always, and that fear and stigma of being given prescription medication stops them from reaching out for help.” Elaborating further, she said that the system in Sri Lanka is such that if an individual registers within a base/teaching hospital, they are referred to a psychiatrist, who then determines if they need a psychologist or counsellor, whereas in any other country, this process is the opposite – which is also the accurate method. “When people are immediately referred to a psychiatrist who may prescribe medication, they panic. Our communication needs to improve and so do our systems. The mass media still has a big role to play in conveying these messages,” Dr. Hettigoda added.  Marginalised and vulnerable communities, and language barriers  “We have no psychologists or counsellors within our prison system. When we speak of an unequal world, prisoners, members of the queer community, and those who are differently abled are a crucial segment. Individuals who belong to these groups may either not be willing to reach out, or may be unable to reach out, which is why we need to look for them and create a safe space,” Dr. Hettigoda stated. Discussing further, she stated that we need professionals specialised in engaging with members of the queer community, as well as the geriatric care segment. She added that we need a system that enables professionals to offer home visits for the differently abled and the elderly, as without this, their quality of life is impacted negatively.  “We also have a lack of Tamil-speaking psychologists and counsellors,” Dr. Hettigoda said.  “Most people who are conversant in Tamil might visit a Sinhala-speaking professional. But, they would not be able to communicate effectively. Again, the government needs to pay attention to this need without delay.”  (In)equality, (in)equity, and the Sri Lankan workplace  [caption id="attachment_166483" align="alignleft" width="290"] Edhati Consultancy Founder Management Psychologist Iranjali Unamboowe Abeyratne[/caption] Sharing her views with Brunch, Iranjali Abeyratne stated that it is important to understand the difference between equality and equity, and how it applies to the theme of mental health in an unequal world. “Equality is when a group of individuals is given the same access to mental health resources or services. Equity recognises that each individual has different circumstances, and uses this recognition to allocate mental health resources/services in a manner that creates opportunities, which are needed to reach an equal outcome,” she said. Explaining further, Abeyratne said that, for instance, we must recognise that children whose mothers are migrant workers have a different set of circumstances, which demand different mental health strategies and resources to be implemented that will allow them to reach an equal outcome as the children who have present mother figures in their lives.  Abeyratne stated that similarly, in the Sri Lankan workplace, there is both inequality and inequity in mental health in terms of income and hierarchy levels: “If a workplace does not by default offer mental health services, only those who can afford or access mental health resources privately will do so. Others will not. Our workplaces also don’t recognise that each employee’s needs are different, leading to a misallocation of resources that does not give everyone a fair chance.”  Disparities in policies and insurance coverage between physical and mental health Iranjali Abeyratne stated that while there have been no policies in the past to ensure the mental wellbeing of employees, this is changing, albeit rather slowly, within certain corporations. However, she believes that the key for any intervention begins with policy, and as such, if there are policies introduced, and a budget allocated for workplace mental health care by the Health Ministry, significant progress could be achieved. “Sri Lanka has seen civil war, the tsunami, the Easter Sunday attacks, and now the pandemic, all the while being a middle-income country, which makes it challenging to allocate a budget for mental health. However, depression is one of Sri Lanka’s most prevalent non-communicable conditions, not to mention our self-harm numbers, which highlight the need for changes at a policy level,” she shared.  Abeyratne also added that while she observes many organisations advocating for mental health and working towards “corporate social responsibility”, the question remains as to whether they offer the same to their own employees: “You can verbally advocate for it, but if the services are not offered in reality, that is an indication that mental health in that workplace is not being taken seriously.”  Discussing the need for insurance coverage that encapsulates mental health, Abeyratne stressed once again on the need for policy reforms. “Corporates could possibly consider standing together to lobby for mental health coverage with insurance providers, potentially leading to a favourable outcome. The same approach can be used to discuss the introduction of policies within our legislation too. If the WHO recognises physiological, psychological, and social health cumulatively as wellbeing and health, we cannot afford to disregard mental health,” she added, highlighting the disparity between the significance given to physical conditions and mental health.  “We have a mental health crisis on our hands. We need a systematic implementation of strategy, along with multidisciplinary teams to level the playing field. We need psychiatrists, psychologists, counsellors, and social workers in both the public and private sectors working together, and in tandem with a national mental health surveillance system, to accurately and equally allocate resources and services throughout Sri Lanka.”

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